In theory Congress' return next week from recess could offer a new beginning to the health care reform process, giving everyone a chance to take a deep breath and recalibrate the components of change.
Nine months into the wrangling around a new Administration, the talk-show right has seemingly hijacked the discussion on health care, Democrats' signature issue, with the standard tools that demagogues have always used: leveraging popular prejudices with oversimplification, hyperbole, and distortion. The die-hard GOP faithful's leaders - Gingrich, Palin and others (see this off-the-deep-end speech by Rep. Mike Rogers (R-Mich)) - are of course playing spoilers, independent of the cost. They hope to goad centrist voters into abandoning the Democrats so they can retake power. Witness South Carolina Republican Jim DeMint's comment, "If we're able to defeat Obama on this, it will be his Waterloo. It will break him."
The problem with this approach is that we're still early on in our national discussion about change and about health care. An increasing number of Americans may be frustrated with Democrats, but after 10 years of Republican rule, few Americans see them as a party of fresh ideas or having an interest in helping anyone but the wealthy and powerful. Americans may have short memories, but they likely still recall that Republicans were just thrown out for a multitude of significant sins. So if everyone you know sends around Obama-as-Hitler arguments, heckling and hoping the Dems will quickly self-destruct may seem like a reasonable strategy. It is doubtful, however, that the other 75 percent of us buy that thinking.
Of course, the Democrats' health care reform offerings haven't particularly helped. As we recently pointed out, now that they're in power the Democrats have taken enormous contributions from the industry, and their health care proposals show it, dramatically expanding entitlements but conspicuously doing little to drive out waste and cost.
This has alarmed some influential groups that otherwise might be supportive. For example, the non-partisan Committee for Economic Development, a business collaboration focused on social issues, issued this July 20th press release excoriating the bills:
"The House of Representatives and the Senate HELP Committee proposals are unacceptable. They would expand coverage without controlling costs, leaving future generations with a system even worse than what we have today. We cannot afford the government and the health-care system we have now, much less this bloated alternative. Lawmakers have bowed to political pressure at the expense of sensible policy. The business and policy community cannot stand behind these bills," said W. Bowman Cutter, Managing Director, Warburg Pincus.
And the Mayo Clinic, often cited by President Obama as a national model for higher quality, more efficient care, issued this strongly-worded response* to the House Tri-Committee Bill:
Although there are some positive provisions in the current House Tri-Committee bill – including insurance for all and payment reform demonstration projects – the proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients. In fact, it will do the opposite.Over the weekend, Senator Mike Enzi (R-Wyoming), a staunch conservative and a member of the Senate's "Gang of Six" working on a health care bill, joined this chorus. He claimed that the Democrats' proposals "will actually make our nation's finances sicker without saving you money," would "raid Medicare" and intrude "in the relationship between a doctor and a patient."
In general, the proposals under discussion are not patient focused or results oriented. Lawmakers have failed to use a fundamental lever – a change in Medicare payment policy – to help drive necessary improvements in American health care. Unless legislators create payment systems that pay for good patient results at reasonable costs, the promise of transformation in American health care will wither. The real losers will be the citizens of the United States.
It is important to distinguish this criticism from most of what we've previously heard from the right. Unlike many of his colleagues, and certainly contrary to conservative talking heads, Sen. Enzi's comments here are not so political as factual. They reflect the legitimate concerns of reasoning, mainstream conservatives who worry about simply throwing more money at health care without fixing anything.
Which constitutes the real health care reform opportunity for Republicans. The time could be right for centrist Republicans to pragmatically wrap their heads around this issue. After all, the approaches that are known to drive down costs and improve quality can easily be embraced by true conservatives who clamor for market-based solutions. Now, out of power and longing to demonstrate that they can produce substantive answers to our problems, the challenge will be to turn against their traditional industry benefactors and act on behalf of the American people.
On August 24th, Bob Laszewski posted an important column, There Will Not Be Health Care Reform in 2009 Without Republican Leadership, that listed four major areas of health care change that should come easily to centrist Republicans.
- Bulletproof Health Care Security. This is the idea that everyone would have significantly improved access to care, that the employer-sponsored system would remain available for those who like it, and that Congress would be required to use the same system that they pass for the rest of us.
- Medical Malpractice Reform. The Republicans have the Democrats where they want them on this one. There is no good reason why our current Med Mal system, as capricious and ineffectual as it has been, has not been revised with expert systems, except that the trial lawyers, in exchange for hefty financial support, have received protection from the Democrats. It's time to fix this problem that pervades our health care provider community.
- Paying for It. This is acknowledging that subsidies will be required for those who can't afford health care at its current cost level, and that there are ways to structure the new cost that are more sensible. As Bob points out, the nearly forgotten Wyden-Bennett bill would be cost neutral in its second year.
- Tough Cost Containment. As we said above, this has been the Congressional Democrats' proposals' most glaring and conflicted flaw. It is an area that, with a focus on primary care, paying for results instead of piecework, and cost/quality transparency, could dramatically drive down cost while improving quality, rightsizing our health system and going a long way toward ameliorating the most pernicious drag on our larger economy. Bob tackles cost control most effectively in his Health Care Affordability Model, a plan that would use tax incentives to encourage the industry to focus on driving out waste.
Collaborating with Democrats or, failing that, taking the lead to demand well-understood cost control mechanisms, would send a clear message that some Republicans are actually interested in problem-solving, not simply nay-saying.
It is possible that the health care reform issue has hardly begun, that the conventional back-room deals and horse-trading needed to be sorted through before the real work could begin. It is a profound truth that, town hall protests and nonsensical boasts about American health care notwithstanding, the middle class is terrified that their access to health care is slipping away. Both Democrats and Republicans have a large stake in visibly resolving this crisis. And, as Rahm Emanuel said, a crisis is a terrible thing to waste.`
The shame and danger of the health care reform proposals so far is that they would likely do little to actually address the crisis. The question now is whether lawmakers in either or both parties can put aside their partisanship, their petty grievances, and their special interest conflicts to do the people's work. Pursuing the structural solutions described here would get America's health care system headed in a new, far more positive direction.
And one thing is clear. The American people are desperate for meaningful health care change, and are watching this process very closely. Whoever takes the high road and achieves real reforms will win. The opposite is also true.
Brian Klepper, PhD and David Kibbe MD MBA write together and consult on health care market dynamics, reform issues, and health IT. Their collected writings can be seen here.
*As of Aug 25 this is what Mayo says about the various health care bills:
August 25, 2009
We support President Obamas call for healthcare reform, and agree with his position that the status quo is the one option that is not on the table. With the President and Congress commitment to reform, we have a window of opportunity now to create bold policy that will translate into real change for patients. Mayo Clinic and the many organizations and individuals working with us in the Mayo linic Health Policy Center are strongly in favor of reform of both health care delivery and health insurance. True health care reform is getting better results for the money spent. Better results for money spent is what we mean by high value health care: better outcomes, safer care, better service and at lower costs over time. If we can accomplish this we will find better access for medical services as well. With many proposals and legislation in the mix, overall we believe there must be two key elements in any successful reform measure:
- Insurance for all, so all Americans have access to health care.
- Payment system reforms that reward value rather than penalizes those who provide high quality, affordable care. Mayo Clinic has laid out an overall Point of View to help guide lawmakers on the elements needed to deliver quality, affordable health care.
- Paying for Value The Mayo Clinic Health Policy Center recommends that Congress focus on "paying for value as the fundamental step required to induce meaningful health care reform. If reforms can align the payment system to reward value, then doctors, nurses, hospitals and other providers will work together in appropriate ways to receive that reward. It may not take much to produce the changes needed to get high value care. Health care professionals have a true interest in providing the best quality care for their patients. If they are rewarded rather than punished as they are in today's system for providing high value care, the payment system will be aligned with their own professional instincts. Most importantly, paying for value will align with what people want: health care that provides good access, delivers quality utcomes, is performed safely, with compassion, and at affordable prices.
- Using Medicare as a lever. We believe the House and Senate have made progress ‐‐especially with reported provisions in the House bill that will help ensure that Medicare pays for value. We are encouraged by reports of provisions to be added to the House bill that addresses both quality and regional variation through two Institute of Medicine (IOM) studies. We believe that provisions such as these must be part of final health care reform legislation.