Politico headline, 1865: Lincoln saves Union…but can he save House majority

The following is a guest post by Dr. Bradley Flansbaum, Chief, Hospitalist Services at Lenox Hill Hospital in New York City.  He is a practicing physician with a strong interest in health policy and engages in advocacy work through the AMA, Society of Hospital Medicine (SHM), and the American College of Physicians (ACP).   He blogs at The Hospitalist Leader.

That line came from none other than Barack Obama at the Whitehouse Correspondents dinner this year, obviously lampooning the glass as half empty, 24/7 news cycle machine .  Normally, I accept the tabloid trough feed of the day, the presumed inspiration for the above laugh line, with my usual healthy sense of disdain or merriment.  However, a recent slew of postings commenting on the shift in Whitehouse and HHS messaging for the promotion of the new health law preoccupied and bothered me.  This type of commentary normally does not get under my skin.

I deliberated and was not sure what I found disturbing, the attacks, the methods of ACA promulgation by its architects, or whether the law itself was flawed, meaning is “is it as bad as they say it is?”

The root cause of the blitz is multifactorial.   As such, it is likely governing philosophy, conservative or liberal, that determines how you perceive and rank the motives.  On that short-list is the troubled economy, poor Whitehouse marketing, folks’ inability to appreciate the complexities of the law, or real gripes with the principles of reform, just to name a few.

The “new” selling points as outlined in the referenced memo are not minor changes as Igor Volsky or Kate Pickert posit.  They read like retractions and timidly portray the law as a less than strident advance.  Knowing the foundation for the less than ideal acceptance of PPACA (and for all you revisionists, remember how six months ago, the country would be “loving” it by now), is a combination of fear, unemployment, and everything mentioned above, I realized it was the attacks that still angered me.  I do not mean the demagoguery, the feeding of meat to the anti-ACA masses, or the snipes.  What I mean is the utter impossibility of anything McCain, conservatives, or the free marketeers could have put on the table enduring the same scrutiny at this juncture in time—and not the claptrap the GOP was pushing last minute.  I am talking a fully realized bill from the principled right.

I wish I could remember who said it, but a policy wonk stated there are four constituents of major importance you must get on board to move a bill forward:  1) the AMA, 2) the AHA, 3) AHIP, and 4) PhRMA/AdvaMed.  Lose one, and you can still move something through.  Lose two, and your dead.

I considered the republicans and the health care summit:  medical malpractice reform, buying across state lines with a Federalized, sensibly designed high-risk pool, consumer empowerment and transparency, etc., all concepts that might work—but with the right tools, safety nets, and oversight (I am a centrist, and not ideologically pure lest you think I am totally ACA adoring ).  Assuming they were in place, where would the advocates of this type of system be six months after passage?  Better yet, what kind of fakakta bill would they have gotten after their journey through the grinder?

Think malpractice reform, actualizing that, and how many pages that portion of the bill would encompass.  An important point the GOP overlooked, or failed to mention, was states oversee tort law and not the federal government.  Can you imagine that legislative headache and the machinations of standardizing anything resembling a national policy?

Even ignoring that, safe harbor creation with sensible use of evidence-based medicine to ameliorate defensive medical practice was also a big talking point.  To wit, a 5-10% reduction in the number of MRI’s, cardiac catheterizations, and unnecessary pathology specimens might be the end game if we minimize unnecessary practice.  Codify that however, and along with the savings, you will have the radiologists, cardiologists, and pathologists with a bit less pocket change.  The AMA, ACC, etc., will not be happy.  Minimizing assurance behaviors also reduces the need to admit diagnoses like chest and abdominal pain, which in turn reduces hospital volume and bed days.  Hospital margins are thin these days, and there is a reason hospitals pay their dues to the AHA.  Expect to hear about it, and keep in mind the most radical estimates of resource overutilization related to defensive practice are 15-20%.

On the delivery front, I recently read a brief from the American Enterprise Institute on the Utah exchange.  What they describe as sensible incremental reform with consumer empowerment, unleashing the forces of the free market that would be a model for national change, to me, is a trial that will play out for years as risk adjustment and quality measurement shake out.  It is not a bad idea, but they will make mistakes aplenty, and I assure you, critics would have a field day.  One man’s “rational evolution” is another man’s wrongheaded experiment.  That is another couple of hundred pages in the bill by the way.

Anyway, overly simplified I know, but you get the idea.  You can fill in the blanks with just about anything conceptually related to health care, left or right and it would all be a jumble 180 days after passage.

In the end, we would have a mash up that the minority–Pelosi and Reid, would describe as a “gargantuan 2000 page failure of the American people that the GOP rammed down our throats!”  Suddenly, a rapacious left would rise up and engage in the same behavior as the conservative detractors I am criticizing now.

My point is that as Aaron and Austin have stated many times on this blog, whether we get to the Promised land with a value-added tax, value-based purchasing, or vouchers is immaterial—as long as it is equitable, fair, and it works.  However, no matter what passed, at this stage, frankly, we would be, and are, stuck with a helluva problem, and opponents need to know their Shangri-La version of PPACA would be no charmer either.  Talk is cheap, and they would be in a similar pickle.

Regardless, I do not worry about repeal or defunding, but I do have concerns about resistant states where the messaging is ugly, and individuals push back and prolong implementation.  Len Nichols said it best: “reform is a participation sport.”  Do not forget PPACA is now law, and there are opportunities for reach outs and change.  Obfuscation and bluster will only hurt most of the folks in this country who are paying gobs (or not) for a system badly in need of repair.  At some point, I hope we can move on begrudgingly, begin to compromise, and make the darn thing work…warts and all.

PS–If you are speculating as to whether we will ever perform a wart-ectomy, this segment is a nice primer on potentially finding a cure.

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