As I discussed briefly last week, the Energy & Commerce, Education & Labor, and Ways & Means committees introduced their tri-comm health care reform bill, America’s Affordable Health Choice Act of 2009 (HR 3200, hyperlinked here for your reading pleasure). The President and others celebrated it as a landmark bill at the White House, while the Congressional Budget Office (CBO) Director, economist Doug Elmendorf, ruined their party by proclaiming the bill as an unsustainably expensive instrument that will destabilize the economy unless modified to reduce costs over time. CBO has always been the "skunk at the garden party" or worse, but this time they made House leaders and the President quite upset.  

What's In It
We strongly support access for all. But the CBO concerns are legitimate. Congress has espoused a set of worthy visions to improve quality and care coordination and efficiency, but the teeth for getting that done -- other than with the same old ineffective price controls -- aren’t yet there. A reform bill that works is certainly still possible after the debate gets going more openly. But, beyond the unspecified vision, the implementation strategies are not there. And, there are a lot of provisions in HR 3200 (many inspired by organized labor) that will alarm many of you if you read all the detail -- just understand this is a political process, and the House knows that most of that won’t survive the Senate’s scrutiny. One real concern for us is that there is no tort reform in this House version, and there probably won’t be anything to start with in the Senate health or finance versions either. 

We applaud the House for its commitment to provide access to health care to basically all US citizens, and in particular for eliminating the SGRrrr for the next 10 years. That’s huge -- $230 billion worth of what would otherwise be cuts to physicians. We praise their huge Medicaid coverage expansion, combined with taking the payment of that program away from states (which have paid on the CHEAP), and providing better payment to physicians. They put a good deal of new money into prevention and primary care, and they add money to offset physician workforce shortages. We also appreciate their establishment of a positive future Medicare physician payment updates (MEI) and favorable spending targets for updates in the future. We’re also well positioned with NCDR and the IC3 Program for their significant payment and delivery reform models, such as incentives for physicians and their expansion and improvements to the Physician Quality Reporting Initiative (although this program still lacks sufficient payment incentives ... a 2% "incentive" is close to useless for most practices). 

ACC President Fred Bove has expressed our praise of these positive elements to the three committees (that would infuse almost $300 billion of new dollars to delivery of patient care), but without praising or referring at this point to the elements of the plan that are undefined (the public option, for example), or to those we must work to amend because they are just plain bad policy (the imaging cuts, their attempt to undermine specialty hospitals, and their attempt to prohibit opting out of public coverage programs). We will work with House and Senate members to eliminate those elements -- none of which should survive Senate Finance scrutiny thankfully. The Senate will not buy the House’s income tax funding approach for HR 3200 as currently configured either. [more]

AMA Endorsement
The American Medical Association has, with some trepidation and hesitation, endorsed the House bill, as have the primaries and the states and several other societies. We owe AMA thanks for taking this on -- the SGRrr fix is a big deal for all physicians, and they (we) don’t want it to die in the Senate. They know their members will not like other provisions of HR 3200, but they made a decision to be at the table in making sure the SGRrr is fixed. Also, AMA has stated clearly that, while primary care needs a boost, it should NOT come from cutting the specialties. Good going AMA.

Because ACC has not issued a blanket "endorsement," we can now help AMA work on amendments where they may be expected to be silent. As CBO points out, the House bill, while containing some positive and visionary elements, is an imperfect, but better vehicle, in terms of the reimbursement aspects as compared to what the Senate is proposing. Remember, POLITICS IS VERY COMPLICATED AND MESSY. But, be clear also that the House members tried their best to come up with money to minimize the hits against doctors, while they cut insurers and home health significantly. We may agree with CBO that the "bending the cost curve" elements lack teeth in the bill, CBO would likely be happy to cut physician reimbursements to fix that. The House tried not to go there. We have to work on the imaging EU elements in their proposal -- and we will.

Looking Forward to Reform
As the details emerge, we too want reform this year but also look forward to more specifics on how payment reforms will ensure that the access reforms are sustainable. Until we completely change the way the payment system is structured in this country, we will never change health care spending, or regain a path to physician practice viability. If the current Medicare 2010 payment rule debacle doesn’t make that clear to you all, nothing will. The current fee-for-service, volume-based concept is unsustainable, and hopelessly and politically complicated to the point of absurdity.

Reform is still going to happen. Harry and Louise, the famous TV ad couple who helped torpedo the Clinton proposal are back on the airwaves, but this time sponsored by the weird combo of PhRMA and Families USA. This time Harry and Louise are worried about losing their coverage, and they WANT health reform now. But what reform? 

*** Graphical rendering of the CBO. From Flickr (fieldsbh). ***