Obama Takes the Ball on Health Reform

President Barack Obama is stepping forward to take ownership of healthcare reform.  In his speech to the American Medical Association, he pulled no punches, emphasizing that while we spend far more than other developed countries, the “quality of our care is often lower.”

In effect the president was telling the AMA: “The U.S. does not have the best healthcare in the world.”

But we do have the most expensive care. Spiraling healthcare bills are “a threat to our economy,” the president declared. “To say it as plainly as I can, health care reform is the single most important thing we can do for America’s long-term fiscal health. That is a fact.” If we don’t rein in runaway health care inflation, he warned, we will be looking at “lower take-home pay, shuttered businesses, and a lower standard of living for all Americans.”

Cutting to the heart of the matter, President Obama explained the problem: “what accounts for the bulk of our costs is the nature of our health care system itself – a system where we spend vast amounts of money on things that aren’t making our people any healthier; a system that automatically equates more expensive care with better care.  There are two main reasons for this. The first is a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I’m talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can’t spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it’s not truly necessary. It is a model that has taken the pursuit of medicine from a profession – a calling – to a business.

“That is not why you became doctors.”

When it comes to practicing evidence-based medicine, the president was blunt “We have the best medical schools . . . . Yet we are not doing a very good job harnessing our collective knowledge and experience on behalf of better medicine. Less than one percent of our health care spending goes to examining what treatments are most effective. And even when that information finds its way into journals, it can take up to 17 years to find its way to an exam room or operating table.”

Here he emphasized the need for comparative effectiveness research: “too many doctors and patients are making decisions without the benefit of the latest research. A recent study, for example, found that only half of all cardiac guidelines are based on scientific evidence. Half. That means doctors may be doing a bypass operation when placing a stent is equally effective, or placing a stent when adjusting a patient’s drugs and medical management is equally effective – driving up costs without improving a patient’s health.

“So, one thing we need to do is figure out what works, and encourage rapid implementation of what works into your practices.  . .  .Let me be clear: identifying what works is not about dictating what kind of care should be provided. It’s about providing patients and doctors with the information they need to make the best medical decisions.”

He acknowledged the argument that so many physicians use to justify over-treatment: “The lawyers made me do it.”

“Now, I recognize that it will be hard to make some of these changes,” Obama acknowledged, “if doctors feel like they are constantly looking over their shoulder for fear of lawsuits. Some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.”
The applause was loud ---so loud that Obama felt obliged to caution the doctors: “Now don’t get too excited  . . . I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.”

But, he added, “I do think we need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine, and encourage broader use of evidence-based guidelines. That’s how we can scale back the excessive defensive medicine reinforcing our current system of more treatment rather than better care.”

Just as he didn’t give ground on caps on malpractice reform, the president stuck to his guns about “fast-tracking” the Medicare Payment Advisory Commission’s recommendations for removing waste from the health care system.  He reiterated his proposal that, in order to raise money for health care reform, tax deductions be limited on those earning over $250,000, insisting that this would not hurt charitable deductions. 

The President Takes Charge of  Health Care  Reform 

Less than two weeks ago, White House Budget Director Peter Orszag gave the New York Times a head’s up:  “Ultimately, as happened with the recovery act, it will become President Obama’s plan,” Orszag explained.  “I think you will see that evolution occurring over the next few weeks. We will be weighing in more definitively, and you will see him out there. ...”

Rahm Emanuel, the president’s chief of staff weighed in, saying that the president’s hope is to provide “air cover” for lawmakers to adopt his priorities. “Obviously,” Mr. Emanuel added, “the president’s adoption of something makes it easier to vote for, because he’s — let’s be honest — popular, and the public trusts him.”

But today’s speech signals that the President is doing more than providing “cover” for Congress. He did not budge on a single issue. He did not use the word “bi-partisan”—not even once.

As Robert Reich recently pointed out on TruthOut.org, the battle is now joined: “The next weeks will show what Obama is made of - whether he's willing and able to take on the most formidable lobbying coalition he has faced so far on an issue that will define his presidency.

“And make no mistake: A public option large enough to have bargaining leverage to drive down drug prices and private-insurance premiums is the defining issue of universal health care. It's the only way to make health care affordable. It's the only way to prevent Medicare and Medicaid from eating up future federal budgets. An ersatz public option - whether Kent Conrad's non-profit cooperatives, Olympia Snowe's "trigger," or regulated state-run plans - won't do squat.

“The last president to successfully take on the giant health care lobbies was LBJ.” Reich pointed out. “He got Medicare and Medicaid enacted because he weighed into the details, twisted congressional arms, threatened and cajoled, drew lines in the sand, and went to war against the AMA and the other giant lobbyists standing in the way. The question now is how much LBJ is in Barack Obama.”

I’m optimistic. Keep in mind: Obama has Rahm Emmanuel covering his back. If someone is needed to scream, threaten, bully and  draw lines in the sand, Rahm is your man. No doubt LBJ knew more about where all of the bodies were buried in Congress, but Rahm Emanuel is, without question, a shrewd strategist, able and willing to play  hardball with Congress.

And many Democrats, including Max Baucus, will need White House support the next time they come up for election. As Watching the Watchers points out in a post titled “How We’ll Get the Public Option”:
 “Obama lost Montana by only 2% or a mere 12,000 votes.  He didn't win the state but he had a tremendous base of support in every county statewide; support Senator Baucus cannot spit on if he hopes to get re-elected.  He will need every one of those votes to keep his job . . .   the situation is not all that different for many of the other key fence-sitters. Obama has strong grassroots support in literally every county of every state in this nation.”

The AMA and the Public Option

Last Thursday,the New York Times reported that the American Medical Association had issued a “general statement of principles” saying that “health services should be provided through private markets, as they are currently.”  In comments submitted to the Senate Finance Committee, the organization wrote: “The A.M.A. does not believe that creating a public health insurance option for  . . . individuals under age 65 is the best way to expand health insurance coverage and lower costs.

 The AMA knows that both the Obama administration and MedPac favor raising fees for primary care physicians, but it frets that reimbursements to specialists for some very lucrative services will be trimmed. 

The Times speculated that the AMA’s opposition could be “a major hurdle for advocates of a public insurance plan. The AMA with about 250,000 members, is America’s largest, physician organization . . .   While [the AMA is ] not the political behemoth it once was,” the Times acknowledged,  “the association probably has more influence than any other group in the health care industry. . . Lawmakers seek its opinion and support whenever possible. ”

But in fact, the AMA now represents only about 25% of U.S. doctors.  The same day that the AMA issued its statement, Obama reaffirmed his support for a public plan.

And then something strange happened.  The AMA backed down. Thursday afternoon –just hours after the Times published its story--the AMA issued another statement, essentially retracting what it had said earlier: “The New York Times story creates a false impression about the AMA's position on a public plan option in health care reform legislation. The AMA opposes any public plan that forces physicians to participate, expands the fiscally-challenged Medicare program or pays Medicare rates, but the AMA is willing to consider other variations of the public plan that are currently under discussion in Congress.”

“Why the quick turnaround?”  Ezra Klein asked on his Washington Post blog. “Hard to say. But that's not a clarification. It's a backtrack. The original statement was not unclear.”

Klein went on to suggest that the administration and its supporters are beginning to take a hard line on reform: “They’re saying that you’re either with health reform, or you’re against it. And if you’re against it you can’t expect to be taken care of in the final legislation. They’re not going to save your seat at the table while you’re trying to burn down the room. And the AMA, it seems, got the message.”
I think Klein nailed it. I just wish I had been in the room when someone in the White House made the call. 

Finding the Money

How will we fund healthcare reform? As part of the budget that was passed a few months ago, the White House put aside $635 billion over ten years in what it called a Health Reserve Fund.  Then the President threw the ball to Congress, saying in effect, now it’s your turn to make some of the hard decisions—and find the rest of the money.

For months, legislators have flailed about. They have suggested taxing everything from junk food to employer-based insurance. Some legislators argue that we just can’t afford health care reform—at least not this year.

Now, the president has stepped forward.  When he endorsed the idea of putting MedPac in charge of Medicare, he pointed out that MedPac knows where money is, because MedPac has been studying the waste in our health care system for years.

In his very reasonable voice, President Obama turned to Congress and said in effect “Hey fellows, I know you’re having a hard time making these decisions. But MedPac knows that there is $200 to $300 billion to be saved . They’ll make the choices for you.

Then, Saturday, in his regular radio broadcast to the nation , the president spelled out, in detail, where $313 could be trimmed from Medicare and Medicaid spending in ways that would encourage both doctors and hospitals to provide better care at a lower cost.

Of course, Congress doesn’t have to go along with the president’s suggestions. But the nation does want universal coverage. Someone has to find the money. Sunday, speaking on NBC’s “Meet the Press,” Vice-president Joe Biden signaled a new attitude in the White House: “They're either going to have to agree with us, come up with an alternative or we're not going to have health care.”

"And we're going to get health care.”

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Ozarks Community Hospital Vision for Change: Visit the OCH Health care blog to read our health reform plan. http://ochhealthcarereform.blogspot.com

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Paul Taylor is the CEO and general counsel for Ozarks Community Hospital. Ozarks Community Hospital is a small health system headquartered in Springfield, MO. He has written the OCH White Paper on Healthcare Reform which is being distributed nationwide. Copies of his position paper can be downloaded at http://www.ochonline.com/pdf/OCHReformWhitepaper2009.pdf. Discussion of healthcare issues featured in the white paper will follow on http://ochhealthcarereform.blogspot.com.