Can President Obama and the GOP agree on improving health reform?

Everything seems to be pointing toward two years of partisan and ideological confrontations over health reform. The leadership of an emboldened Republican party has made it clear that it will use its newfound House majority to seek to “repeal and replace” the Affordable Care Act (ACA), and if that doesn’t work, to “defund” it. Huge GOP gains in statehouses make it likely that more states will resist implementation. Meanwhile, President Obama has stated that he is open to “tweaking” the law but not “re-litigating” the health reform debate.

This is a debate that neither side is likely to win.

Let’s start with the Republicans. They believe that they have a mandate to seek repeal of the ACA, but they won’t be able to deliver. The House GOP will run smack dab into a Senate that will do what the Senate does best, which is to bury legislation that comes out of the House. Senate Democrats will use their majority – and the filibuster, if needed – to block efforts by the House to repeal or reverse key provisions, and President Obama will use his veto pen if necessary.

Plus, when it comes to specific changes, the GOP may find that they don’t have the public’s support. Do voters really want the new Congress to repeal the prohibitions against insurance companies charging more to people with pre-existing conditions? Do they want to give up their “free” preventive services and annual Medicare wellness exam? Will they want to give up the promise made by the law that if they lose their jobs starting in 2014, they won’t lose their health benefits?

What about physicians? Do they really want Congress to take away the 10% increase in Medicare payments for primary care to be in effect for the next five years? Do they want Congress to withdraw funding to raise Medicaid primary care payments to the Medicare rates? Do physicians want Congress to defund programs intended to reverse a growing shortage of primary care physicians? Do they want Congress to halt the redistribution of unused residency positions to general internal medicine and family medicine residency programs? Do they want Congress to stop the federal government from enforcing rules to require insurance companies to standardize, simplify and reduce paperwork on physicians and patients?

What about the programs created to lower costs and improve outcomes? Will the new GOP House, which has complained that the Affordable Care Act doesn’t do enough to control costs, want to eliminate funding for comparative effectiveness research and the new Center on Medicare and Medicaid Innovation – two of the most promising avenues to lower costs and improve outcomes? And if the GOP were to repeal the savings in Medicare from reducing payments to hospitals and Medicare Advantage plans without finding offsets, the result would be a whopping $500 billion increase in the budget deficit, according to the CBO.

By committing itself to a “repeal and replace” agenda, the GOP risks alienating many voters for trying to dismantle popular parts of the law, disappointing its base for failing to get rid of it, and upending its promise of deficit reduction.

This doesn’t mean that President Obama or the Democrats necessarily will have the upper-hand. The fact is that the President has been unable to persuade a huge chunk of the electorate that the Affordable Care Act will make health care more affordable. Instead, many believe it will lead to higher premiums, more government spending, and more debt. As long as this is so, the Affordable Care Act will continue to be politically vulnerable, and many Democrats who support it will continue to be at electoral risk.

There is another option than for both parties to engage in a no-win fight over repeal. They could look for ways to make improvements that preserve the key elements of the ACA – including the promise to provide coverage to most Americans – but allow for testing by states of free-market approaches to delivering such coverage.

They could start by allowing states a great deal of flexibility in setting up the health exchanges. The Washington Post reported on Tuesday that with GOP gains at the state level, “two models are likely to appear: Democratic governors and legislatures are likely to emphasize vigorous regulation and government oversight, while Republican state leaders are likely to put greater stock in privatization and other free-market approaches.” States could experiment, for example, by offering health savings accounts on an equal playing field with other insurance products. HHS Secretary Sebelius has already signaled a willingness to consider states’ requests for waivers from certain ACA requirements.

President Obama and Congress could also agree to expand upon and accelerate the authority granted by the ACA to allow insurance to be sold across state lines. They could agree to a serious effort to make real reforms in the medical liability system, such as authorizing and funding a national demonstration project of health courts. They could even commit to a bipartisan effort to reform Medicaid to make it a more effective and affordable program. And while they are at it, they could get a bipartisan deal on reforming physician payments and repealing the Medicare SGR.

For all of this to happen, though the GOP would need to back down from repeal being the only acceptable option and accept the law’s commitment to provide most Americans with affordable coverage. President Obama and his congressional allies would have to be willing to give the states more options to implement market-based reforms, to recognize that not every program created by the ACA is of equal importance for funding, and to show courage in making medical liability reform a priority.

The political dynamics are such that none of this is likely to happen, but I think the country would be better off if they tried.

Today’s question: Do you think President Obama and the GOP can agree on improvements to the ACA, or is the polarized debate on “repeal and replace” our inevitable future?

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.

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  • MatthewBowdishMD

    I am not sure where Mr. Doherty has been for the last two years, especially on Nov 2, but the American public and a majority of physicians do not support this law. Just look at the recent 2011 National Physicians Survey (http://www.hcplexus.com/PDFs/Summary—2011-Thomson-Reuters-HCPlexus-National-P):
    -65% docs say quality of care will deteriorate in next 5 yrs, 18% says it will improve
    -78% docs say impact of ObamaCare will be negative for docs, 8% says it will positive
    -58% docs say impact of ObamaCare will be negative for pts, 27% says it will positive
    -45% didn’t know what an Accountable Care Organization is

    As a physician, I tend to agree with majorities of my fellow doctors who see new rounds of capitation and rationing outlined in this bill adversely affecting patient health rather than improving it. Had I known that the PPACA was in my future, I would have chosen another profession instead of becoming an employee of some ACO, rationing the care of my patients. Unfortunately for me, I am no where near retirement age as many of my colleagues who will be able to leave medicine.

    As an American citizen, I also see this bill leading to a tremendous overreach by HHS, CMS, IRS, etc., thus destroying the notion of an America where we have a limited federal government. If the Commerce Clause was really meant to allow the federal govt to force citizens to buy a product from a third party, then there isn’t anything the govt cannot force you to do…buy a GM car, buy GE products or even regulate what kid of diet you eat. In essence, the PPACA ends the ideal of America.

    As a person who wants real health care reform based on American values, I find the bullying of our leaders in the AMA, ACP, local medical societies, in Congress and the White House to accept this horrendous law quite ugly and deserving of the same derision as is being heaped on autocratic govts around the world.

    Bob Doherty does not speak for this internist/allergist, and if it takes another election to turn over the Senate and the White House before this law is repealed, then so be it.

    • Jeff Taylor

      Yours is just the rather tired old position of antiquated principle denying modern reality. You have no ‘limited government’ solution to solving our healthcare problems – no private insurer would by choice take on pre-existing conditions. No free market solution exists to replace Medicare. And with the amount we spend on healthcare – far higher than elsewhere per head – no docs are going to starve and many more people can be cared for by eliminating huge amounts of waste, although I’ll grant that our country does not have a good track record of using resources wisely.

      • DougPete

        Jeff, your arguments are hollow. Our country spends more on healthcare than others because it provides better technology and services. That’s why people from other countries come here for treatment. That’s why, in most cases, patients live longer, more enjoyable lives and don’t have to wait months or years for surgeries.

        Are there problems with our healthcare delivery? Of course. Lower income earners do not have adequate preventive care and maintenance for chronic conditions. We can fix that. But our system already provides everyone who has an immediate health issue whether they have insurance or not. While it isn’t cost effective for this care to be delivered through ERs, we can develop better methods.

        Why disassemble the world’s best overall healthcare system to fix the 10-20% of it that isn’t functioning the way it should? Does that make sense?

        Of course there’s waste and fraud now, but do you think those will be reduced when the government runs the whole shebang? Get real. There is no government run program that is more efficient than what the private sector can provide with the exception of the millitary.

        I’m still surprised doctors aren’t more vocal with their opposition to ACA. When the government holds all of the chips, they will lose their ability to determine how they practice and what they prescribe. They will become cogs in The System instead of independent, innovative professionals.

        You say there are no free market solutions for providing pre-existing conditions insurance and ways to replace Medicare. Perhaps you feel that way because you’re not looking beyond systems already in use. The free market can solve all of these problems if the government will provide leadership and then get out of the way.

        • Jeff Taylor

          You’re wrong on several points, such as life expectancy (lower than many European countries), happiness (massive amounts of mental illness here) and spend/benefit (the overtreatment in our system is staggering).

          And you’re wrong that the ‘free market can solve all of these problems’ (eg. seniors care). No company will insure older people with chronic conditions and no company will offer affordable policies to younger people with preexisting conditions.

          • http://fertilityfile.com IVF-MD

            Jeff, I agree the free market can’t “solve all of these problems”, especially since one of the biggest factors in health is aging and death. My challenge to you is to convince me that your authoritarian central-planning, especially WITHOUT creating even more problems of national economic hardship.

            Neither free market nor government regulation can solve all problems, but the argument stands that peaceful voluntary solutions work better in the long run than coercive authoritarian ones.

          • Jeff Taylor

            IVD,

            I’m familiar with health systems in Europe and I would say that your loaded term ‘authoritarian central-planning’ is more like a silly McCarthy red under beds thing than any sensible comment. Look at Germany, France, Netherlands etc to see excellent models of public/private health systems that cover everyone without bankrupting the countries.

          • http://Www.twitter.com/alicearobertson Alice

            Jeff…if you remove our very high auto accident fatalities, and homicide rates I believe from a healthcare only position (minus our cultural problems with murder and accidents) if we compare on a level playing field our lifespan is as good or better than Europe. We have better cardiac and cancer survival rates…less infection, etc. Same with infant rates that are not compared in an exact fashion as data should be. Countries report infant deaths by different criteria.

      • http://Www.twitter.com/alicearobertson Alice

        If they gave us our money to makes some of our own decisions a private free market could help. Also, they should consider letting the private free market run our schools and senior care. Right there it would cut down on waste. For the vast amount of money they have of our’s a private enterprise could employ and insure many people (Obamacare will take another 16000 IRS agents just to torment the citizens and employers to cough up the fines…and something like 150 new bureaucracies to run it. Did you read about the two huge bureaucracies in the NHS in the UK the new PM Cameron is abolishing because of waste and need to keep his 80/20 ratio cut? The 20 billion in dollars or pounds that is cut over 4 years? And people need to understand the UK is about the size of New York and PA so that is a ton of money to cut. People will be hurt and die because socialized medicine is fictional romanticized care…not reality),

        About that life span remark…na da….America has the best cancer care rate in the world amd if you remove our extremely high auto accident death rate and homicide rate we have the best life expectancy. Ours is more of a crime and bad driving problem because we still offer the best care in the world because our free market encourages innovative treatments we get before any other country, and we have the best and newest medical equipment, procedures and drugs.

      • MatthewBowdishMD

        If the Constitution is tired, old and antiquated, then count me in. There are plenty of limited govt solutions to health care reform. I would list them in great detail if I was confident you would care enough to consider them. But since you seem intolerant of any view other than a top-down rationing approach to medical care. I didn’t go into medicine to keep from starving. I spent 10 years of my life and $220K in loan debt to care for patients in a personalized approach, not to manage NPs to go through supposedly evidence based algorithms. I also went into medicine to be a small businessman, and guide my own future. I will do fine financially regardless…that’s not the issue. The issue is whether every medical decision I make with my patients will be political in the future. People like you seem to want only abortion to be decided between a patient and doctor. What about the rest of your health care choices? Do you really want me to be forced to limit them without your approval?

        • family practitioner

          I am not intolerant to other views.
          Please share your ideas.

    • Ed Sodaro MD

      100% correct.

      The American People hate ObamaCare.

      Repeal this nightmare. Replace with something workable and legal.

  • Anonymous

    I’m still surprised doctors aren’t more vocal with their opposition to ACA. When the government holds all of the chips, they will lose their ability to determine how they practice and what they prescribe.

    Probably because the PPACA still leaves much of the system in the hands of the same private insurance companies that will try to ration care as they do/did already before the PPACA (by denying stuff they are supposed to approve, throwing bureaucratic hurdles at providers and patients, etc.).

    The rapidly increasing cost of US medical care is going to be a train wreck in the future, with or without PPACA. Arguing about PPACA is just partisan bickering that won’t stop it from happening.

  • http://www.twitter.com/alicearobertson Alice

    Let’s start with the Republicans. They believe that they have a mandate to seek repeal of the ACA, but they won’t be able to deliver. [end quote]

    And what if the Supreme Court rules on this…and they are likely to…..and, personally, it would seem the conservatives have a better grip on the constitutional aspect. It may not agree with what others view as a human right…but mandates like this should be contested. So, should the question about what Constitution says about the rights of man.

  • Joe

    It seems both sides could agree that the healthcare information technology thing has gotten out of hand. Progressives don’t have a regulator and conservatives want to remove the incentives. Outcome analysis doean’t support patient care improvement and economic analysis doesn’t support efficiency improvements.

    Why can’t they agree on taking out the HITECH part of the stimulus?

  • AA

    Warning, rant coming.

    Personally, I found Obama Care lacking in many ways but do we really want to go back to the days where people are excluded due to pre-existing conditions and other factors?

    I keep hearing this can be fixed but no one is coming up with solutions.

    As one who barely qualified for my current insurance policy due to being considered to have a psych med history even though I stopped taking them last year, many of you folks have no clue how terrifying it is not to have health insurance.

    I had a previous period where I couldn’t get any thanks to my so-called pre-existing condition.

    Even now, my policy is quite limited and I greatly fear using my health insurance out of fear it will be canceled or costs will greatly increase.

    By the way, in case you have forgotten, people are dying due to not having health insurance. And please don’t give me the BS that this is voluntary. It definitely isn’t.

    Folks who do have health insurance are going bankrupt.

    By the way, what good is it to have the best health care system in the world if people can’t access even basic services?

    I wish to god I could move to a country where this wasn’t an issue but unfortunately, I am too old to do so and I don’t qualify for medicare. I try to do what I can to stay healthy but as we all know, sometimes you end up in a hospital due to no fault of your own.

    I greatly fear going bankrupt due to not having adequate health insurance and no one seems to give a darn except to resort to the usual arguments that do nothing to solve the problem.

    Stepping down from my soapbox

    • imdoc

      Part of the ‘uninsured’ problem here is that health insurance is less like real insurance and more a pre-paid benefit plan. If it were not provided by employers, and individuals could purchase protection for liabilities over a large deductible, the insurance market would more closely resemble auto or property insurance. Also, there is tremendous market concentration, with some carriers having dominance in areas which means every doctor must sign up to stay in business. No patient should have to go bankrupt from this system. The current system favors lack of price transparency.

      • http://Www.twitter.com/alicearobertson Alice

        Employees get a perk for insuring which some feel makes it unfair for the self employed. Then add that the government is already the key player…if you add the people who qualify yet do not apply the liberal figure of uninsured people goes down…but then you have more people with the ability to use government insurance.

  • Dr George

    The reform is bad. The methods used to push it through were bad. It needs to be repealed (probably can’t happen until the democrats and Obama are voted out) or declared unconstitutional which I guess will be decided by Justice Kennedy as the others will tie 4-4. I think the judge using Obama campaign argument that forcing us to by insurance to solve healthcare would be like forcing everyone to buy a home to end homelessness. If they get this power, we are all doomed. Next they will mandate we all have electric cars to solve global warming/cooling/change.
    Healthcare challenges are because we developed a system where the user of a service does not pay for it as they use it. If we had developed a program where the employer paid for your groceries, and we paid a small copay for everything we bought, we would have a grocery cost problem. The government cannot solve the problem because they created it and added on with Medicare and Medicaid. Now the solution is to expand programs that are already not working. The other problem of course is end of life costs. Most of what we spend on healthcare is spent in the last 12 months of our life as we use ever available test, technology, and service to wring another month of life. Yes, we live longer, but with what quality of life. Government run care is killing other countries and the technology and quality is way down as stated by others when we see everyone with money coming here for care from around the world. Market solutions are the only ones that work along with everyone paying for the services they want to have. If you need 20 bodies a day going into your Pet scanner, it will have to come at a price people who really need it can afford. It would get all the folks making a living on the stupid plan we have today looking for other things to do.

  • alice

    Jeff……maybe I am wrong but I think you said you work for an American firm overseas? If true that would make the socialist mindset understandable…yet…it would also mean you have private insurance?

    I think I shared with you that I am married to someone from the UK and have lived there and my husband and kids can get free care ther…no thank you. I have been studying different healthcare systems around the world and completely disagree with the fairytale about countries you list. Many European countries cannot sustain this financially…look at France and the trouble their system is in….Germany is digging out of socialism…and we know about the UK…then travel a few hours north of me to Canada where Premiers come to the states along with some other PM’s and the rich who pay out of pocket to get away from socialized medicine and their cut rate catastrophic care.

    And let us add that it is because of the American free market that Canada and Europe have good drugs without all of our risk. They wait awhile then buy it in bulk….which means people in these countries do not have the quality of care our free market innovates. Cut the freemarket and you cut some lives. Quality of care goes down on everything but mostly treatable problems because socialized medicine is good at the small stuff.

    Read some of the letters from the Royal Colleges in the UK. Those doctors are pleading so desperately with Parliment you find yourself thankful for insurance…as Europeans with private insurance are.