Did Martha Coakley kill health reform, and what Senator Scott Brown means for healthcare

In case you haven’t heard, in a stunning result in yesterday’s special election in Massachusetts, Republican Scott Brown won the Senate seat previously occupied by the late Edward Kennedy.

Needless to say, pundits are going crazy analyzing the results, and its implications on health reform. I’ll leave the political commentary to them, but I’ll comment on what this means for health reform’s future.

In essence, what turned into a 95% likelihood of passing, now stands at no better than 50/50, if that. The Democrats are now faced with an array of unpalatable options, which Slate’s Timothy Noah has concisely outlined.

I’ve previously written that the Democrats’ approach to health reform was seriously flawed; there were not enough mechanisms to control costs, a lack of meaningful malpractice reform, and an implicit contempt for the medical profession that most progressive reformers harbor. But most of all, reformers failed to listen to the needs of perhaps the most important constituents: patients and their doctors.

Not enough was proposed to strengthen the patient-doctor relationship, and there was little language on facilitating the practice of medicine. The most important commodity doctors have is time, and the reform bills did not value it. The lip service paid to primary care was encouraging, but in the end, the proposed remedies fell far short of what was needed.

All that being said, I still supported the legislation, arguing that seriously flawed reform was better than nothing:

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.

In the end, I have messages for both sides of the political spectrum.

To the Left, listen to the doctors. Your antagonism towards the medical profession is harming your cause. Polls show that physicians have tremendous influence on patients. Although I agree that delivery system reforms are needed, these decisions should be made in conjunction with physicians, not solely based on the opinion of health economists with little clinical experience.

And continually harping on physician salaries does little to bring doctors to the progressive side. As renowned Princeton economist Uwe Reinhardt says:

Physicians’ collective take-home pay [is] only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

We need to focus on decreasing the disparity between primary care and procedure-based specialties.  That needs to be the dominating narrative, not the incessant progressive assertions that “doctors make too much money.”

A piece of advice to my progressive friends.  The best way to win over doctors is to take medical malpractice seriously. More than a few will gladly accept a single-payer system if explicitly paired with comprehensive liability reform. Even with the most conservative, non-partisan, CBO estimates, fixing the malpractice system will save $54 billion over 10 years, which is not insignificant.

To the Right, with the potential defeat of ObamaCare, you may have won the battle, but will lose the war. The current health reform efforts, in the grand scheme of things, were very incremental in nature. Without it, the number of uninsured will rise, and health costs will continue to spiral upwards. That will eventually bring America’s economy to its knees, and, as I said a few months ago, “once that happens, more draconian measures will be forced upon us. Measures that assuredly will not be friendly to doctors.”

The Health Care Blog’s Matthew Holt comes to the same conclusion today: “The next approach will come at a time of extreme need, and the response will be a lot less palatable than many inside the system would like.”

And those wanting to “start over” are in for a rude awakening.  There will be no next time, as no other administration will want to tackle health reform after this debacle.

Indeed, if health reform fails, a more progressive solution will be forced upon the country – Medicare for all, for instance – making conservatives wish they had cooperated with President Obama’s approach today.

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  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    I have only skimmed over your post this morning, Kevin.

    I will sit down to read it in more detail later . . . over some breakfast TEA;)

    http://drjshousecalls.blogspot.com/2010/01/that-wasnt-thunder-at-arlington.html

    It’s WAY past the time for the Democrats/Obama adminstration to put the brakes on what they’ve been doing and start talking to doctors (all doctors as opposed to the relative minority speaking for us via the AMA) about what real reform means . . . instead of stomping all over them . . . as they’ve done since the days of Bill & Hill’s village.

    Attention NC Congressional reps: My e-mail is on my profile, and phone lines are open.

  • jsmith

    Kevin, your comments are all very reasonable and you’ve convinced me. I’m just sorry that the left and the right have been listening to nobody but themselves for quite some time now. I’m worried this will all end badly, for our patients, for the country, and for our profession.

  • http://www.entrepreneurialmd.com Philippa Kennealy MD MPH CPCC PCC

    It is a sad tale of the times and of self-centered politicking that health care reform is once again the victim of ego and the need of one group to dominate another, rather than doing what is right for the people of this country. Is this the price we have to pay for allowing the rights of the individual to supersede the good of the community?
    Any step towards reform, no matter how imperfect, is better than the chaotic mess we have now.
    I despair for us when we behave like school ground kids thumbing our noses at each other for our partisan “wins”, when, as was so eloquently stated above, the war will be lost (not that I love war metaphors — there’s too much of that going on to be glib about it).
    When will we find it in ourselves to work together to the very solve problems that so many families and individuals are experiencing in this broken system?
    I guess our crisis isn’t deep enough yet to mandate resolving it!

  • renee RN

    Your insight is appreciated, but I think you missed the point on this one. The conservatives have been available to work on healthcare – THEY WERE SHUT OUT of all the closed-door meetings. I am not sure why this keeps getting missed? Letters of request were sent to the President, and, by all accounts, ignored.
    People are demanding transparency – which is what was promised, but which HAS NOT yet been delivered. That was the change they voted in last year, and that is what yesterday’s election was all about. In effect, the people have been able to slow down this runaway train, and it will now be up to the Congress to work together to keep it on track. The scope of reform is immense and may be better tackled in phases.
    At the very least, I would hope for nonmaleficence from Congress. Given how many decades it took to make a mess of the current system, it may be better to do nothing in the short term, than to do something that may cause further harm. “Starting over” is perfectly acceptable. There are 4,000+ pages of bureaucracy to be reviewed. If the House and Senate were able to draft these bills under a “crisis” situation, Congress should be able to draft another that will protect the American people and their access to care. (And NOT ONE state in the union should be getting any “quid pro quo” deals, lest they be making deals with Hannibal Lecter, or the devil himself…)
    The actual crises in healthcare are the GLOBAL physician and nursing shortages. If the government wants to do its part here, let them provide citizens with FREE tuition to college. Then everyone truly would have the opportunity for higher education, and there would be no large loans to repay. Malpractice insurance and tort reform is also a must – we are driving OB-GYN’s out of practice with the current system.
    With healthcare reform, it is critical that the dignity of the person be the nexus from which all other issues are determined for “patient-centered” care. Health care delivery itself is NOT a commodity; it is an experience between the providers of care and those receiving it. Somehow, this gets lost in economics of it all. Real cost-containment will only come to pass when the paradigm has shifted fully from a reactive medical model to a preventive/proactive model, with patients understanding they have the primary responsibility here. If we are able to accomplish this, it will be a medical model that can be replicated around the globe.
    In closing, we should be challenging those in Congress to be obligated to ACCEPT the same version of healthcare they would provide us with. Only when the stakes become personal will the negotiations become serious.

  • Healthcare Observer

    ‘When will we find it in ourselves to work together to the very solve problems that so many families and individuals are experiencing in this broken system?’

    You’re asking for a narrowing of a political gap that is as wide as ever. You don’t get round this by ‘working together’ – by definition democratic politics is about struggle and defeating the opposition with a mandate and a majority, which the Dems still have.

  • Rod

    very sensible approach for both sides. congress, please read this before it is tooo late:( It is not a number game, peoples lives are hanging in there, unfortunately those that can not speak for themselves are the ones that are affected the most if there is no bill.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Renee, I totally agree about people being shut out of the process, as well as the concept of starting over. And tort refom is simply a must. It’s not being addressed at all – mostly because most politicians get their start as lawyers.

    But, I’m sorry. We already provide enough “free” education and “free medical” care (and it ain’t “free). Some things in life are not meant to be “dumbed-down” or made easier. Higher education is called higher education for a reason – and if people really want/are qualified for one, there are ways to go about it (as I did – white/middle-class/didn’t qualify for much of any aid . . . only to get resoundingly burned in public service . . . mostly for being so naive & idealistic as to believe that “non-profits” were “charitable” organizations, and the government would actually do what it said it would/enforce its own contracts & laws).

    It’s time to STOP playing the entitlement/victim cards. Life, liberty and the PURSUIT of happiness. It’s a nice cake already. The rest is icing.

    Dr. Kenneally, if you think Brown’s victory is about partisianship, you could not be more mistaken – although there IS (don’t ya just love that word?) an argument to be made that the Dems (who in my experience, tend to be two-faced anyway – in a “two Americas” kind of way), were making a lot of broad/very LIBERAL assumptions about what Americans want, and using their fragile majority/”mandate” like a battering ram. It wasn’t very “progressive” at all. Obama may be from Chicago, but you simply cannot run America like the Mob.

    What we really need to address are the issues of accountablity (real accountability), transparency, ethics and PERSONAL RESPONSIBILITY in medicine, law and government.

    This adminsitration – this Congress – isn’t doing that, and that’s why the Independents who voted for Obama (merely a year ago) bolted, some Dems outright revolted and a now Republican now sits in Ted Kennedy’s chair.

    For those of us on the front lines and receiving ends, it was a SWEET thing to see happen. The PEOPLE have spoken.

    One can only hope someone is listening.

  • http://www.entrepreneurialmd.com Philippa Kennealy MD MPH CPCC PCC

    The election may not have been about partisanship (being a Californian, I confess ignorance about the personalities and their political positions in MA), but the national reactions are. As they were in Nov 2008.
    It’s normal human behavior to crow when you win and savor the victory (hopefully just for a while), but isn’t it then time to soberly assess what the REAL work is that needs to be undertaken, and get to it?
    I hold both sides of the table (along with any Independents!) accountable to work out their differences and get something meaningful and useful accomplished.
    From where I sit as a disillusioned physician who left clinical practice out of sheer frustration, given the suspicion and bitterness that color the attitudes of the people we have elected into office (as well as the divided electorate), I do not hold out much hope that we can arrive at the desirable and admirable state of “accountability (real accountability), transparency, ethics and PERSONAL RESPONSIBILITY in medicine, law and government.”
    How do we achieve this accountability? How do we even define it? And who’s going to be first to step us and take personal responsibility? I’m eager for ideas.

  • Healthcare Observer

    ‘I hold both sides of the table (along with any Independents!) accountable to work out their differences and get something meaningful and useful accomplished.’

    With respect Philippa this isn’t going to happen on anything meaningful. The GOP voted to a man and woman against what is really modest reform. History tells us that in the western world things like votes for women and blacks, and workers’ rights, were only gained through huge struggle and sacrifice. Those with power and money do not as a rule sit round a table and give it up politely.

  • http://www.entrepreneurialmd.com Philippa Kennealy MD MPH CPCC PCC

    Hey Healthcare Observer

    I can dream, can’t I?? :-)

    However, I AM intrigued by the notion (and I say with all sincerity that I AM paying attention to your words and chewing on them) that you equate universal access to decent healthcare alongside women’s and blacks’ rights to vote, considering that this isn’t even questioned in most European countries.
    It highlights for me one of the mysteries that I haven’t fully grasped, despite my 25+ years in the US — that there really IS an American mindset that needs to be respected and taken into account. It was alluded to in this post by another physician:
    http://medinnovationblog.blogspot.com/2010/01/middle-class-unrest-and-massachusetts.html
    Problem is, if this is indeed true, then what happens to those in this country who are for whatever reason unable to tap into “self-reliance, economic progress, private independence, religion, historical traditions, social activism, decentralization, and distrust of government elites telling them what constitutes the “public good” or “common good.” “?
    Perhaps the next ML King of Healthcare is due to surface – I guess that is what I am hearing.

  • ninguem

    There was a big step toward reform in 2004.

    HSA’s. They are now 20% of the private insurance market with no government assistance except getting out of the way. They really do “bend the cost curve”, year after year, insurance company after insurance company, the data’s out there. Not only were they deliberately ignored, but the prople who claimed to be “reformers” actually worked to kill them with this surrent debate. Rockefeller from West Virginia as just one example.

    Want to take the next step? How about a Shadegg-type bill, allow people to buy insurance across state lines? Yes, I know the theoretical objections. Fine. Let’s find out. If it fails, it can be repealed.

    No, why make incremental steps, when we can wipe out the entire system, put clauses in the law to make it impossible to repeal, kill the private market entirely, and ruin the country in the process?

  • Evinx

    Disappointed. Not one word in the article or comments about the finances. Medicare for All is not going to happen – we cannot afford the existing medicare program.

    Reform is needed on how to address and allocate a scarce resource. It needs to address supply and demand factors. When CVS offers simplified healthcare for routine vaccinations and simple illnesses, that is reform from the marketplace. When robotic surgery becomes more commonplace, that too is reform. When medical tourism becomes more widely known , that also is reform. Yes, some of us may not like it, but that is the wisedom of the marketplace speaking.

    The American populace does not want the top-down reform from Washington. That should be clear. What they are asking for is Washington to get out of the way, give consumers and patients and medical professionals more freedom. That is the message.

    Special Interest Groups and lobbyists are acting, of course, in their own self interest – and that impedes market based reforms. Haven’t you heard the people complaining about the politics of healthcare, the special interest groups, the lack of freedoms, the restrictions, etc? The public does not want a govt managed healthcare system. They know about govt run projects and costs and bureaucracy.

  • Paul MD

    When it comes to “all things Constitutional”, I generally sit just to the right of Attila the Hun. Only incarcerated peoples are Constitutionally afforded health care by those resposible for their charge.

    I did grow up in the Peoples’ Republic of Massachusetts and am more in touch with the sentiments of those who are not part of the corrupt nepatistic political system or their employed minion.

    There are many who were insulted by the idea that the vacant Senate seat BELONGED to Ted Kennedy. Trust me, he was NOT universally loved and admired. There are many, mostly independents, who are outraged at the arrogance of the Democratic leadership in Washington. This election result was a reforendum and not an aboration as some would like it to be portrayed.

    I firmly believe that the spoiling of the Democrat supermajority is a good thing for the country. We, in medicine, are still trapped between the left (who hate us) and the right (who doesn’t want to pay us). Ultimately, if medicine goes to hell, I would rather fall on my own sword than sit back and be stabbed by the intentions and will of a wrong thinking congressional majority.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    “We, in medicine, are still trapped between the left (who hate us) and the right (who doesn’t want to pay us).”

    Paul, that is THE BEST description of the great divide I’ve heard in a long while.

    Right now, Philipa’s questions remind me of a scene from “Interview With A Vampire”, in which an angry (relative newbie) vampire, Louis de Pointe du Lac, argues with the 400 year-old Armand about their origins and chides him for not giving him any answers . . . Armand shoots back,

    “But you asked the wrong questions!”

    Apart from the massive sense of entitlement on the part of huge segments of society, the biggest PROBLEM that we have right now is that too many outsiders to the professsion . . . with their own selfish agendas . . . are LITERALLY RUNNING IT . . . without asking the right questions of the doctors and nurses in the trenches and on the front lines . . . people with the actual experience (and scars) from fighting the good fight (and for most of us, it IS a good fight).

    What makes it exponentially worse is that these people really running our show do not care about us. It’s only about buying power and votes . . . or making their next bonus . . . and giving away our labors “for free”.

    And/so, I guess what I’m saying is that the way you get things started is to ASK THE RIGHT QUESTIONS of the people who are actually doing the job/providing the service (that would be doctors & nurses). You don’t shut doctors out of the process or rob them of their voice.

    Economically and practically speaking, it is NOT all about the consumer. There have to be good reasons for providers to stay in the game that you, Philippa, left.

    And (here’s a thought) you do whatever you can to make their jobs easier and more productive. I daresay you could save trillions by giving medicine back to the people who practice it (and their patients) . . . by taking some of the middlemen/suits OUT of the picture.

    You do not dictate. You do not bully. You do not micro-manage – or regulate doctors to death.

    You actually work to define many things about the laws we already have which have been left to chance or interpretation.

    You also start simply, and progress in steady increments . . . not with some monster bill that will create far more problems that it solves, and will have far more “unintended consequences” than we can imagine

  • http://fertilityfile.com IVF-MD

    There is all this talk that all of a sudden, we have a healthcare CRISIS and that any change over what we have today would be a vast improvement. I’m wondering where was this outcry, for example, 15 years ago? Was there no crisis then? So, was the average American better off or worse off 15 years ago, 30 years ago or 45 years ago if he/she got sick?

    I realize the massive complexity of this whole healthcare infrastructure, but if we were to try our utter best to explain things to a 7th grader, how would you say that these reform bills in any way, would make things overall better for people?

    Before you answer, I might have you ask yourself if you are just stating a fact of reality:
    “Healthcare is expensive”
    “People are getting sick who don’t have coverage”
    “Doctors and/or pharma and/or insurance companies and/or lawyers are greedy”

    If so, that’s not really an answer as to why these changes would necessarily make those things any better. I would be open to hearing, for my own growth and education, something along the lines of how anything in these bills could represent an overall superior way of letting things run.

  • Blake

    I don’t understand why there has not been a broader push for a state incentive to create a system of increased health care delivery and coverage. This does not have to be limited to expansion of Medicaid. MA and HI, as the two that I know about, have extended healthcare coverage to most of their citizens, and they seem to be relatively happy about it. People from Hawaii, to my knowledge, at least, are pleased with their system of mandating that all employers provide health care plans. At worst, if they are not happy about it, they can be happy about the prospect of leaving the state for another that has a better system.

    We talk so much of marketplace competition to produce health care reform, why is there no talk of state-level competition to initiate reform? If Georgia creates an excellent system for patients, but a poor one for physicians, then docs leave and Georgia is forced to reevaluate and fix it. Florida could create a great system for physicians and leave patients out to dry, causing an exodus of elderly patients from Florida to Texas, forcing Florida to reevaluate their system. Why is this not a tremendously better idea than a Federal, one-size-fits-all system?

  • Evinx

    Blake – you are 100% correct. It should be left up to the states. The reason the Feds get involved is bcs the states want money – everyone wants someone else to pay for healthcare. That is the big game going on. It gets further complicated bcs the Feds force hospitals to take patients that have no means of payment – at least to the point of getting them stable. There is a giant game of cost shifting going on.

    That said, the best solution would be for states to experiment and do as their local citizenry asks. I’m with you – and in fact, aside from national defense and some interstate issues, that is what we should be doing in lots of areas.

  • http://fertilityfile.com IVF-MD

    Blake, I’m with you.

    Taking power away from distant federal politicians and giving it to individual states would do a lot of good.

    The principles of COMPETITION and ACCOUNTABILITY would both thrive and whenever there is more competition and more accountability, overall quality increases.

    This is actually how this nation was originally set up before some gradual shady political maneuvering amassed more power into the hands of a central federal govt.

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