Healthcare reform is an achievement but isn’t perfect

Heading into the final weekend of Mr. Toad’s Wild Ride, who could have guessed that in a year that brought us Death Panels, Pickup Trucks, “You Lie”, The Cornhusker Compromise, Bart Stupak (boy, that must have been a tough name to grow up with), and the Senate Parliamentarian-as-Rock-Star, we would be on the cusp of passing a perfectly acceptable healthcare reform bill, a once-in-a-generation legislative achievement.

Unmistakably, the mojo has shifted back to the Democrats – it is amazing how a dour and monolithic opposition can cause even Dems to unite for a common cause. Our President has also learned a few lessons, including the importance of symbols, populism, and singing with one’s diaphragm. (We knew we were in trouble a few weeks ago when Rahm started being criticized for not being sufficiently Machiavellian.) With yesterday’s CBO figures showing that the reform plan will save nearly $150 billion, even fence-sitting Democrats now see more political risk in saying No than Yes. That, of course, is the most relevant calculus, and with it more and more of the Blue Dogs are entering the Yes column each day.

The politics were fun enough, but the thing that’s most remarkable is this: The legislation that now seems likely to pass ain’t bad. To an impressive degree, the crazy deals, the budget sleights-of-hand, and the extremist positions have been or will be stripped out of the final text. The bill will manage to cover most uninsured Americans. Its new revenue streams are not magical: higher taxes on wealthy Medicare recipients, some take-backs from generously funded Medicare HMOs, and some (watered down to keep the unions in line) new taxes on “Cadillac” health plans. The most heinous aspects of the under-regulated insurance system – particularly the exclusions for preexisting conditions and the possibility of losing insurance after becoming ill – will become memories of a crueler American past, like slavery and McCarthyism.

Not perfect, you say? Sure, the legislation is not perfect. Not everyone is covered. The problems with the malpractice system remain largely unaddressed. Hard decisions about promoting quality, safety and efficiency are kicked down the road. Lots of newly insured people won’t be able to find a primary care doc. Care will remain fragmented and chaotic for the foreseeable future.

But even in these areas, the winds are blowing in the right direction: support for comparative effectiveness research; experiments with bundling, Accountable Care Organizations, and Medical Homes; promotion of improved transitions; malpractice pilot studies; a small dose of steroids for MedPAC.

And maybe, just maybe, a renewed sense that Washington can tackle hard problems.

Even the most infuriating examples of demagoguery may have silver linings. The whole Death Panels thing made me ill (particularly when I learned that Governor Palin supported legislation to promote end-of-life discussions in Alaska precisely one year before she went on her cynical Death Panel tirade), but the topics of rationing and how we approach end-of-life care are crucial and really sticky. When we return to them, as we inevitably will, we’re likely to have less heated, more thoughtful discussions, having gotten some of the craziness out of our system this time around. Just think about the tenor of today’s public debates over legalizing pot, gays in the military, and stem cell research – the topics remain lightning rods, but the discussions are much more civil and thoughtful than those of a decade ago.

All in all, the legislation being considered this weekend is sufficiently reasonable and centrist that it can resist the playground name-calling (“Socialist!” “Government Takeover!). The fact that it has no chance of attracting a single Republican vote speaks volumes about cold political calculation, and relatively little about the nature of the changes the bill will usher in. This is, in fact, a bipartisan bill – one that deftly splits the difference between lefties who want single payer and massive government involvement, and righties who want to “keep Government out of my Medicare!”

Watching the process was nauseating, but if I could have gone into a deep sleep after the Obama election and awakened this weekend to find Congress passing the bill it is now considering, I would have said, “Hey, that’s not too bad.”

Unfortunately, I stayed awake for the whole thing, and I may never eat sausage again. But that doesn’t change the outcome.

Or the fact that the system, to a remarkable degree, worked as the Founding Fathers hoped it would.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • anonymous

    you apparently are a smart guy.
    you take the absence of Republican votes to be a political process and still claim the bill to be bipartisan. creative new interpretation of existing words is always fun.

    maybe you are too far removed from taking care of patients without housestaff? the funding for the bill and the creating of layers of bureaucracy without address malpractice reform make it a terrible bill for most physicians. how exactly do you justify support to your primary care colleagues in the trenches who you admit are going to be swamped?

  • montana

    The only part of this bill that I think is nonsense is the pre-existing condition clauses. A reasonable person with any business experience understands that the health insurance industry will NEVER, EVER accept pre-existing conditions.

    Corollary: I have a barn on the back of my property that was heavily damaged by lightning 5 years before I bought it. It’s (pre-existing) condition is not insurable. Why would/should ANY insurance company be forced to insure and repair it?

  • Dr. Mary Johnson

    I’m gonna have to agree with the anon here (horrors!).

    Sure. This bill is great. Nevermind that . . . “The problems with the malpractice system remain largely unaddressed.” . . . (And) Hard decisions about promoting quality, safety and efficiency are kicked down the road.”

    Dr. Watcher, those of us who are bruised and bloodied from fighting those battles – VERY IMPORTANT BATTLES – are not going to be hopping your hope & change train. We cannot go to sleep – because we know that kittens & puppies won’t be lapping at our faces when we wake up.

    I should have been invitied to testify before Congress (about my experience in government & non-profit medicine) long ago. I expect I haven’t because what happened to me (in Hillary’s village) does not reflect too kindly on the current Democratic agenda.

    Watching the process was indeed nauseating. So here’s another point-of-view . . . from a non-academic who has lived and worked in the trenches with the dogs and cats:

  • SarahW

    Where to begin – Section 1513 is an abomination…but there’s so much more. Perverse incentives that make the situation worse, not better.

    Better to start over an reform in a different direction.

    This bill will take insurance and access to care away from people, and fine them for the privilege. It will allow unprecedented intrusion of the government into our private contracts.

  • BladeDoc

    Is it any surprise that someone who chooses to practice in the most liberal city in the most liberal state finds this bill “centrist?” Seriously now. This bill combines 1. a mandate that everyone buy health insurance but penalties that are far cheaper than any comprehensive policy (the only type that are ok) with 2. guaranteed issue and 3. a ban on recission it is obvious that people will avoid buying health insurance until they are sick. Health insurance will become truly unaffordable under these circumstances and the feds will have to “fix” it by creating a federal insurance program.

  • Trious

    As a patient who reads this site for insight from doctors, I just want a change. I am tired of how complicated and expensive the current system is….I want something done to stop people from being dropped for little to no reason OR dropped when they need the Health Insurance more than ever after paying for it for many years.

    Republicans seem to offer nothing different. Democrats offer a plan that I am not totally on board with but dammit, I just want something different.

  • Dr. Mary Johnson

    You just want “something different”?

    Well, it’s gonna be “different” for sure.

    Be careful what you wish for. And do not say you were not warned.

    • montana

      …health-reform logic:
      1. We need to do SOMETHING.
      2. THIS is something.
      3. Let’s do THIS.

  • SarahW

    Trious, now it’s MORE complicated and more expensive – for individuals and employers.

    Section 1513 is a travesty. It encourages employers to turn away employees with larger families or disabled family members or stay-at-home spouses. That’s because there is a 3000 penalty to the employer if your FAMILY income dips below a certain level, and you opt for a subsidized insurance plan instead of the company plan.
    THe penalty isn’t based on what the employer pays employees, but what the employee’s family makes.

    It encourages firms with lots of low-income employees to drop insurance altogether, because it caps the fee to 750 a head, cheaper than the headache and cost of insurance.
    Middle-income employees in such a firm, who wouldn’t qualifiy for a subsidy, are on their own now to find some plan they can afford, risking penalties from the IRS if they choose wrong, which will probably cost more than an employer plan and which will be paid for with after-tax dollars, (no tax breaks like an employer gets) and which will have limited coverage. Result: Worse insurance that lowers your discretionary income. You are WORSE OFF THAN EVER.

    And more people on the subsidized plans means even your access to a physician or facility or treatment is uncertain.

  • ninguem

    Montana’s barn…………..

    The barn is insurable. In fact, I can tell you the premium for the policy.

    The cost to tear down the old barn, build a new barn, plus an administrative fee. That’s the premium.

    Expect something similar with health insurance. When all the insurers are put out of business by government policy, you can expect a single-payer system to “Save Healthcare”.

    Wait in line. Oh, of course, the politically connected will jump to the head of the line. Some are more equal than others.

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