The health reform legislation signed into law by President Obama on March 23 represents a historic shift in the federal government's role in health care, but debate continues about whether it will be good for America.
Republicans, without exception, voted against the bill, and House Minority Leader John Boehner (R-OH) predicted that it would lead to the country's ruin. Democrats countered that the legislation is an advance in social justice on par with Medicare, Social Security and the Civil Rights Act, and that voters will soon warm to its benefits, just as they did with these other laws. The debate won't be settled any time soon.
For its part, ACP advocated for policies that have long been embraced by its membership. The final legislation was by no means perfect, but on balance, it merited a “yes” vote in Congress because it would advance long-standing goals on patient coverage, workforce levels and payment reform.
ACP also believed that if the legislation was defeated, it would be many more years before a president and Congress would again take up the cause. In the meantime, rising costs and premiums would push affordable health care out of reach for most Americans.
It is difficult to predict what the legislation's impact will be. But there are at least six key elements that can improve the lives of internists and their patients:
- 1. An estimated 95% of legal U.S. residents will have access to affordable health insurance that cannot be taken away because they get sick or change a job. Some 32 million Americans without coverage will soon have access through Medicaid or through tax credits.
- 2. Small businesses, including many small internal medicine practices, will have access to group purchasing arrangements called health exchanges. Some will also be eligible for tax credits.
- 3. Patients will have guaranteed access to evidence-based preventive tools, such as cancer screening tests, at no out-of-pocket cost.
- 4. Medicare and Medicaid payments to primary care internists will increase. Beginning in 2011, general internists who provide mostly primary care visits will receive a 10% Medicare bonus for their office and other outpatient visits. And beginning in 2013, Medicaid payments for primary care visits will be increased to no less than the Medicare rates.
- 5. Medicare patients will benefit from better coverage of preventive services, lower co-insurance and premiums, and a phase-out of Medicare's prescription drug “doughnut hole.” Because the legislation will reduce spending on hospitals, drug companies, Medicare Advantage plans and other non-physician providers, more can go toward the Medicare Part A (hospital insurance) trust fund, which will remain solvent for nine more years, instead of running out in 2017.
- 6. More money will be authorized to train more primary care physicians through the National Health Service Corps and other programs.
Still, many Americans are wary, feeling that we can't afford the cost of the legislation. The Congressional Budget Office estimated that the bill will lower the deficit by at least $143 billion over the next five years, and by over $1 trillion over 20 years. But long-range budget forecasting is notoriously difficult. The legislation also gives the federal government more authority to test new ways of aligning incentives for physicians, hospitals and other providers with the value and efficiency of care provided. But experts disagree on whether these will be enough to “bend the cost curve.”
The long-term impact of the increased federal role in health care is also harder to assess. The legislation does not give the federal government authority to deny care based on costs or to dictate decisions to physicians and patients, contrary to critics' claims. It doesn't create a new government insurance program. Yet the federal government will have the authority to fine individuals who do not buy insurance and to regulate insurance companies to ensure that they provide essential benefits and don't discriminate against people with pre-existing conditions. And because the federal government will assume a greater share of health care costs, critics argue that future cost controls will lead to rationing of care.
Another uncertainty is whether there will be enough primary care physicians to care for a growing population with more access to health insurance. Provisions in the legislation to train more primary care physicians and improve payments may not be enough to rapidly increase their numbers.
Health reform is a work in progress. The legislation has the potential to improve lives, “bend the cost curve,” reduce the deficit and increase the numbers of primary care physicians. Whether it strikes the right balance between government regulation and private initiative will continue to be debated. As the program is phased in, a certain degree of wariness and a willingness to make mid-course corrections are needed.