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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