Thursday, January 14, 2010

Obama's Pickle

President Obama has found himself in quite a pickle concerning health system reform.

After visiting several members of Congress yesterday, mostly Democrats, its apparent that there is no broad consensus on the final outcome of the Bill.

From the beginning it appeared the President was going to capitalize on his booming popularity and the majorities in both houses of Congress. When you combine that with the back slapping endorsements from the physician trade group (the AMA), the hospitals, and big pharma -- before they even had a chance to discuss the components of the bill -- it seemed like a slam dunk.

But, oh what a mess we find ourselves in. First and foremost is the tenuous nature of the Democratic majority. The first attempt at HSR in the House was a modest Bill, some problems, but tolerable from a patient care standpoint. It passed with a few vote margin but likely could have been more with some arm twisting from the Speaker. Several D's were allowed to vote "no" in an effort to pander to their conservative base in an election year.

Then the Senate creates their own bill: a monster that reorganizes modern health care delivery, provides no increased provider incentive, and creates a "block grant" type funding mechanism with the IMAC proposal. The IMAC, or "Independent Medical Advisory Committee", is especially worrisome. In effect, Congress would defer funding decisions for Medicare to an independent board appointed by the President allowing Congress to be "off the hook" in future budget cuts.

The other problem is the doctors. The AMA for many years has not been the "voice" of the practicing physician. With membership numbers vague, but probably hovering around 17%, this organization makes its income from product sales and services. So their endorsement was a hollow ring for most physicians. They put their eggs in the basket of a fix in the funding mechanism (the SGR, or Sustainable Growth Rate formula) which was denied by the Senate. They told their membership they needed to keep a "seat at the table" -- but that's not happening -- more about that later.

So now the decision is being made by Pelosi, Reid, and Obama. The current conventional political wisdom is that we will find ourselves with a bill that looks mostly like that one from the Senate. But it remains to be seen if the House can stomach the proposals and if Pelosi can hold her troops together.

Getting the 218 votes in the House from just the Democrats might be more difficult than if he had worked on a bipartisan piece of legislation from the beginning. I just can't help believing that we would have ended up with some remarkable health care reform if the President had worked more closely with the Republicans.

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