March 01, 2009
4 min read
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Health care reform: It is happening faster than most of us are aware

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There is widespread bipartisan agreement that the United States spends too much on health care and that our current system is too disjointed. With the new president's plan for health care reform, all of the signs indicate that it will have more government controls than we have ever experienced.

Douglas W. Jackson, MD
Douglas W. Jackson

Before President Obama even announced any changes, we saw expansions of health care entitlements that were added into the economic stimulus package. These changes will incrementally lead us into an expanding national health care program. Once these entitlements are in place, it is unlikely they will be rescinded.

Most Democrats in Congress are committed to introducing a stepwise increase of government control of health care rather than one sweeping change. This became apparent in 2007, when Speaker of the House Nancy Pelosi (D-Calif.) attempted to expand the SCHIP (State Children’s Health Insurance Program) bill. The Republicans defeated that first attempt. However, President Obama in January signed the SCHIP reauthorization bill into law, calling it a “down payment” on his future plans to provide coverage to all Americans.

Driving private insurers out

The SCHIP legislation will cover 4 million children by the year 2013. They will be added to the 7 million already covered by existing programs. The Congressional Budget Office estimates the program may allow as many as 2.4 million people to be able to drop their private insurance on their children. The bill will also provide for federally backed funding to care for children and pregnant women who are legal immigrants, as well as for families of four with household incomes as high as $66,000 in certain states.

In a statement made the day the bill passed in the Senate, Sen. John McCain (R-Ariz.) said, “I must ask, is the intent of this legislation to provide coverage for low-income children, or is it the first step in driving private health insurance to its knees?”

The new program is to be financed mostly by a 62-cent increase in federal tobacco taxes. Ironically, it could be completely financed and more by the money Medicare would save if cigarette smoking ceased altogether.

Medicaid and COBRA

Another recent and not-so-obvious entitlement expansion was summarized by Rep. Pete Stark (D-Calif.). Stark has worked for health care reform for years and is positioned to be the “enforcer” of many of the coming changes. He and other Democrats are currently pushing changes that will increase health care entitlements — all during an unprecedented financial crisis.

In a New York Times article on the Medicaid and COBRA (Consolidated Omnibus Budget Reconciliation Act) changes that are included in the stimulus program, Stark said, “We accomplished more today than in the past 8 years.”

COBRA has become another entitlement that extends medical coverage for people who are over the age of 55 years and between jobs until they are eligible for Medicare.

The bill will also bail out those states with failing Medicaid health care programs. Therefore, it appears that the government will end up providing our tax dollars to the states with the least fiscally sound, underfinanced and overly exuberant spending programs. It appears that the more they have spent, the more they will get.

Other changes will allow those receiving unemployment checks to be eligible for Medicaid. These increases will all be subsidized under the umbrella of the new stimulus package.

I am amazed at how quickly these new entitlement programs have advanced. This has occurred without many debates on the long-term consequences of the undetermined financial costs or on the timing of the programs during a yet-to-be-defined form of national health insurance.

Quick moves

This methodology follows some of the strategy former Sen. Tom Daschle advanced in his recent book, Critical: What We Can Do About the Health-Care Crisis, on lessons learned from failed attempts at health care reform. He expressed that previous health care reform was impeded by too much discussion occurring over an extended time period. He proposed making change quickly without many debates, or with well-coached explanations and vague wording of the bills.

In my commentary in the February issue of Orthopedics Today (Daschle and Baucus: Two players in the new era of health care reform, page 3), I wrote how influential I felt Daschle and Baucus would be in future health care reform. After that issue went to press, Daschle removed his name for consideration for the position of secretary for the Department of Health and Human Services (HHS). It was a good move. Had he not dropped out and was appointed, it would have suggested that two tax codes exist: one for individuals and one for the political establishment. Many of you have under gone audits and know firsthand that the IRS does not accept “I forgot” or “I did not know” as an acceptable explanation.

Federal council

Another example of underestimating the costs of all the changes to date is the $1.1 billion program to establish a Council for Comparative Effectiveness Research. This will not go for outcomes research that could result in reducing future spending. It will involve making decisions on providing reimbursement only for treatments that it deems to be beneficial and cost-effective. I believe this will eventually lead to the council overseeing the rationing of medical care and services like similar European health care systems.

All these recent expansions have occurred before the confirmation of the new HHS secretary or Obama’s revealing his plans for health care reform. Our attention has been focused so much on the new and almost daily disturbing financial news that most have not focused on the giant strides government entitlements have been making.

This year we will face imposing challenges as proposed and enacted economic stimulus and health care reform bills alter the financing and practice of medicine and, concomitantly, the care of our patients.

Douglas W. Jackson, MD,
Chief Medical Editor