Dear Mr. President:
You won on health care.
Campaign on it.
You won historic legislation in 2010. Your advisors told you
to change the subject and campaign on the economy. You lost the mid-term elections, big time.
You won a victory in the Supreme Court this week. The same
advisors who counseled you then are at it again. I don't know what economic
accomplishments they think you should run on.
I know a few things about what you've done in health care.
The Affordable Care Act instituted system reforms in how we
pay doctors, and how they practice medicine, that are reducing the actual cost
of health care. This is tremendous news. It is not showing up yet in reduced insurance
premiums. But your law makes it possible
to do so.
Health care spending growth has
slowed from double digits to 4% or lower. Further, hospital admissions are
down, even among insured people. Writing in Health Affairs in April
Kenneth
Kaufman states that
"independent
of the recession, other fundamental and structural changes are likely
contributing to the flattening of the cost curve, and further, these changes
have the potential to significantly alter the curve’s path into the future."
Kaufman quotes Jeff Goldsmith,
Ph.D., President of Health Futures, Inc., who "suggests that the makeup
and organization of the nation’s physicians is one source of the slowing cost
growth. Physicians of the past 30 years typically practiced in solo or small
group practices. Under the fee-for-service system, they were incentivized to
work long hours, see as many patients as they possibly could, and buy into
labs, ambulatory clinics, and specialty hospitals. As a result, they tended to
be high users of inpatient and outpatient services. These more entrepreneurial
physicians are now reaching retirement age and many tens of thousands are
opting to exit the workforce. Replacing them are physicians of a new
generation, which has different work and lifestyle expectations. For many
younger physicians, owning a practice is not as important as having time to
spend with the family and a steady, predictable income.
"One effect is that physicians
have sought employment by hospitals...and in larger group practices, many of
which now employ hundreds of doctors. They are practicing medicine in ways that
remove utilization and cost from the system. Protocols to reduce variation in
care delivery, chronic disease management, case management, and other approaches
are increasingly being adopted by physicians nationwide. Larger practices owned
by hospitals and other entities will have the capital and human resources
required to successfully reduce care costs through such approaches, slowing
health-spending growth going forward."
Other efforts include "moving
from an activity-based business model that incentivizes utilization of services
to a value-based model that incentivizes population health management across
the continuum of care,"
Why aren't we seeing lower
insurance premiums, then?
First, the insurance industry isn't
yet sufficiently regulated.
The
Exchanges starting in 2014 will make regulation more likely.
States can use the ACA now to regulate on their own.
A progressive new Congress could create a
competing public option, and allow states to create entirely public financing
systems like Medicare.
Secondly, the
system reforms are not yet universal.
In
fact, some physicians are turning to "boutique" practices where they
can take only wealthy patients who will continue to pay whatever high fees the
docs require to maintain their incomes.
The political good news is that the
opposition program will clearly hurl us right back into the days of
double-digit health care cost inflation, while cutting seniors and others out
of access to care. Surely impressive information for the American people.
The Ryan/Romney proposals would
turn Medicare and Medicaid into voucher systems. Every person would get a coupon worth a
certain dollar amount, and go out and look for the best deal from doctors,
hospitals, and drug companies. This
means bringing the kind negotiations from the car dealership to the hospital
every time we and our families get sick.
For most rational Americans, not an appealing prospect. It is certainly the end of Medicare.
The opposition hounded Dr. Don
Berwick out of his position as administrator of the Medicare program, precisely
because of his expertise in the kind of system reforms that are now working.
Mr. President, you need to stand
with the many patients already benefiting from the improved coverage and
consumer protections provided by the ACA, and fight for a second term that will
propel us forward towards universal, affordable health care.
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