The House of Representatives has cleared the first major hurdle facing a sweeping health care reform bill by voting to pass the bill. The vote was extremely close, with 220 votes for passage of the bill and 215 votes against. A grand total of 39 Democrats voted against the bill and only one lone Republican voted in favor of it.
The bill was passed after weeks of deal-making, adjustments, and fine-tuning, all of which was headed by Speaker of the House, Nancy Pelosi. In the end, several concessions had to be made in order to secure the necessary votes for passage. First, Pelosi gave up on the federal funding for abortions in order to appease the right to life proponents and several important religious groups. Second, she had to increase the income level that would trigger the new tax-surcharge that will help pay for the bill. Finally, she was forced to “water down” the public option by allowing doctors to negotiate with the public option just like they do with the payers. When the final bill came to a vote Saturday, it was almost 2,000 pages long and had a price tag of $1.2 trillion dollars.
The next hurdle for health care reform lies in the Senate. The Senate must now find the 60 votes necessary to begin a floor debate and then be able to overcome an expected Republican filibuster. This could prove to be a much more difficult task than Pelosi faced in the House. As soon as the House bill was passed, Senator Lindsey Graham was quoted as saying "The House bill is dead on arrival in the Senate." Senator Joe Lieberman, an Independent who caucuses with the Democrats, said that if a public option was present; “As a matter of conscience, I will not allow this bill to come to a final vote."
So what gives? Here are the two main issues facing the Democrats in the Senate: The tremendously high cost of the bill and the ever-troublesome public option. Senate Majority Leader Harry Reid has to figure out a way to keep the public option (which the more liberal Democrats want and the House needs) but also to “water it down” or change it so that the moderate Democrats, Independents, and at least one Republican will vote for it to pass. Truly, it’s the political equivalent of the worlds most difficult tightrope walk.
One option is to allow states to opt out of the public option. Another option would be to have the public option triggered if costs continue to increase. But each of these options appeal to only some and not to others in the Senate. While its still too early to tell what version will ultimately make it to the floor of the Senate, it is clear that it will be more about what version can get the 60 votes and less about what is really necessary to reform the health care system and to control costs. What is worrisome about this entire process is that the most important thing now is passing “a” bill and not necessarily passing the “right” bill.
Assuming the Senate does find the 60 votes necessary to avoid reconciliation (which, by the way, could be disastrous), the next step would be for the Senate and House leadership to merge the two bills into one piece of legislation. Then, that bill would go back to both Houses of Congress for a final vote. There is still a great deal that needs to be done before anything can officially arrive at President Obama’s desk for signature. There are many more deals to be cut and many more compromises to be made before we even get a glimpse of the final health care bill that could eventually become law.
So what does all of this mean for physicians? There are two main things that should be of concern to physicians. First, how the managed care companies are reacting to all of this and second, how this will affect both Medicare and the SGR.
Managed care companies are viewing this legislation as a huge threat to their business models. This is why they have spent obscene amounts of money lobbying against the Democrats’ push for reform, and more specifically, against the public option. Many physicians whom I have spoken with are taking pleasure in the fact that this is causing the insurance companies extreme fear and dismay. While I can truly understand all of this excitement, I have to caution physicians about getting too excited. You see, when insurance companies are threatened, they generally take out their frustrations on physicians. In fact, I am already seeing this happen. Across the country, I am seeing insurance companies getting more aggressive in negotiating their contracts with physicians. Believe it or not, I have actually had a managed care executive explain a significant reduction to one physician group by saying, “We have to take these actions to get ready for the public option.” I have also experienced a great number of payers say that they are “putting a freeze on all physician negotiations” until they see what comes out of Washington. Now, that’s certainly nothing to be excited about.
All of this is happening before we even know if any bill will pass and if it will even contain a public option. Keep in mind that the current bills don’t have the public option actually becoming effective for at least three years. So, my point is that if the payers are already taking these kinds of measures in preparation for the health care reform bill, what do you think they will do once the legislation is actually passed?
A final factor in the middle of this whole mess is the current Medicare SGR that is calling for a 21% reduction in the Medicare conversion factor effective January 1, 2010. A few weeks ago, there was an attempt to eliminate the SGR, but disappointingly enough, that legislation died before it even got off the ground. Now, it seems likely that with all of the attention on the health care reform bills, no legislation regarding the Medicare cuts bill happen before the end of the year and Congress will take up that issue after the new year. The issue at hand is the cost of getting rid of the SGR. Eliminating the 21% reimbursement cut will increase the deficit by over $200 billion dollars. Imagine a scenario in which some form of health care reform gets passed. Let’s assume that its something like the House bill and it has a price tag of over $1.2 Trillion dollars. Now, let’s imagine that the Democrats eliminate the SGR reduction for 2010 and pass a band-aid bill that will add another $200 billion to the deficit for 2010. The Republican’s mantra in the election year of 2010 will be that the Democrats are taking over health care and spending our children’s money. You won’t be able to turn on a TV without seeing a Republican ad, replaying the President’s state of the union address where he pledged not to sign any bill that would add one dime to the deficit.
The bottom line is that the politicians in Washington are playing some very high-stakes poker and a good portion of our physicians’ hard-earned money is sitting in the pot. The best advice we can provide to physicians is to stay informed and stay active. There is still time to impact this debate and make sure that the people in Washington don’t reform health care and control costs by creating a system that will be detrimental to physicians. You didn’t cause this problem, and the solution shouldn’t be crafted on your backs! Let your elected officials know your position on the matter. Make sure they understand that the most critical position in the entire health care system is the physician and that any solution that drives doctors out of practice or forces them to provide sub-standard care is no solution at all.
While it’s still too early to know exactly what the outlook will be for doctors, it’s safe to say that unless doctors make their voices heard, it’s not likely to be very pretty.
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