Sunday, August 2, 2009

What #HealthReform will look like

Gazing into my crystal ball I am getting some idea of what the final healthcare reform product from Congress will be. The devil is in the details, and there are still many to be worked out, but we can see some broad areas where I feel safe making predictions. The areas of coverage, access, costs and quality will be addressed (albeit probably not comprehensively). There are different aspects of each of these areas which overlap, and a change in one area of the healthcare system will have effects throughout the system. Today I will look at coverage and access.

In the area of coverage, we will see a public option plan. Many decry this as a government take over of the healthcare system. But as Paul Krugman said, "Getting the government involved in health care wouldn’t be a radical step: the government is already deeply involved, even in private insurance." The government already covers about 100 million Americans. Medicare dominates the market, stifles competition, and sets arbitrary and unfair pricing standards. Many want a single-payer system. When I met with Senator Merkley yesterday I asked him directly did he support a single-payer system and he said, "Yes I do, but that will never happen this time around." I tend to agree. The momentum is certainly against this option, so a compromise will be the public option plan. Many believe that this is a trojan horse to eventually implement a single-payer system, and for some that is certainly the plan. Rep. Barney Frank admitted that a public option is the best strategy to move towards single-payer because they do not have the votes to pass it now. If it was all or nothing for single-payer right now, there would be no health reform passed. It would kill the deal. We will see a multi-payer universal enrollment system, much like what they have in Switzerland, Japan, the Netherlands, Ireland, and Australia.

With regards to access, by adding coverage for millions of additional patients we will seriously exacerbate the shortage of primary care physicians (family doctors, general internists, geriatricians and pediatricians). of about 50,000 which we already face. The argument that these folks already get healthcare via the emergency room does not mean that we will have adequate resources for them to find family primary care physicians to care for them. Since it takes eight to 12 years to educate and train a primary care physician we have a steep climb to fill the gap. In the Physicians' Foundation survey of 270,000 primary care physicians, virtually all of those now practicing in the U.S., revealed that 54 percent planned to retire or see fewer patients within the next few years; 60 percent said they would not recommend medicine as a career for their children; and 36 percent said Medicare does provide adequate reimbursement. We are already facing a crisis, and expanding coverage will worsen the doctor shortage.

The health reform package will attempt to address these issues by establishing primary care based medical homes to coordinate and provide comprehensive care; cutting medical school debt for doctors promising to practice in underserved regions of the country; and funding to help expand the number of medical schools, the number of medical students in existing schools and the number of training programs for primary care residencies. This will be an expensive but necessary component of any successful reform efforts.

Later I will take a look at possible reform efforts in the area of cost and quality. One thing I will say is that it is unlikely that we will see any tort reform included. The political process is going into overdrive this summer, and there is going to be extensive lobbying pressure applied. Some of the more controversial elements (threats of a single-payer system, abortion, end of life counseling for seniors) will be removed as compromise takes place to buy votes in congress. Pork filler will be added and the end result will be a bloated, bureaucratic beast that may or may not make healthcare more affordable, accessible and higher quality for everyone.