Current Reform Legislation May Just Be Round One

As the insurance companies and other industry sectors mounted new assaults on the reform bill that the Senate Finance Committee is about to vote on, it is starting to appear that the current legislative battle is only round one of what will likely be a protracted campaign for universal health care and cost containment.

Susan Dentzer, editor of Health Affairs and former health correspondent for the Lehrer News Hour on PBS-TV, noted on NPR’s “This American Life” program last weekend that the reform bills contain provisions that would give the Secretary of Health and Human Services new powers to determine how Medicare pays physicians and hospitals, and that the new Medicare commission proposed in the Baucus bill would also have a lot of authority over government reimbursement policy. But she pointed out that none of the payment changes are likely to be embodied in the legislation itself, because that would be politically unacceptable.

“If you try to build all of this into the bill right now-if you say we’re going to make sweeping changes in the system-we’re going to pay you in a completely different way-we’re going to take you doctors out in the hinterland, collecting your fee-for-service monies, and basically restructure the system in such a way that you might have to live your life very differently-just try putting that in a bill that gets everyone to accept it. You can’t.”

That may be true, but at least one Administration official is not pulling any punches. Dr. Ezekiel Emanuel, who works closely with White House budget director Peter Orszag on health policy issues, told the attendees at the annual Medical Group Management Association meeting in Denver that a “high touch” approach to patient care could reduce costs by avoiding hospitalizations and ER visits. That “high touch” approach, which involves a greater emphasis on primary care and non-visit care, would require that doctors be paid in a different way, Emanuel suggested. According to Modern Physician, “[Emanuel] asked audience members if they are ready to provide high-touch care under what will be a change in the way they are reimbursed for care, ‘because I think it is going to change.’”

Other health policy experts are divided on how far and fast to change the system. Gail Wilensky, a former Medicare chief, says that the current bills should require that successful pilot projects to contain costs immediately be incorporated into Medicare. Stuart Altman, an economist at Brandeis University, believes that Congress, like the Massachusetts legislature in 2006, plans to tackle coverage first and address cost control later. But Len Nichols, a health economist at the New America Foundation, says the Baucus bill sends a strong signal to the provider community that the old way of doing business is coming to an end.

Perhaps. But I suspect that the health system will have to be very near total collapse before any of the players will give up anything that they have without a fight.