Wednesday, January 19, 2011

ACA: Repeal and Implementation

Today the House of Representatives voted to repeal the Affordable Care Act (ACA) in what is viewed as largely a symbolic action because the Democrats control the Senate and President Obama would veto a straight repeal in any event. I think meaningful compromises that would improve the bill are available, but it is unclear whether today is the just the start of Republican health policy efforts in the 112th Congress, or the pinnacle. Time will tell.

During the repeal vote, across the Potomac in Crystal City, Va. a 28 person negotiated rulemaking committee (I am a member of the committee) that was created by the ACA was diligently working on one small piece of the nitty gritty of implementing the law: considering changes to how the federal government identifies Health Professional Shortage Areas (HPSA) and Medically Underserved Areas/populations (MUA/P). These designations make local areas and populations eligible for special resources to help address shortages of primary care providers (like the National Health Service Corps, Medicare physician bonus, etc.) and/or extreme health care needs (Community Health Centers, Rural Health Clinics, etc.).

The means of designating HPSA and MUA have been largely unchanged since the 1970s. The Clinton Administration attempted to revise these methods, but the proposed changes were rejected during the federal rulemaking process as constituencies affected by the changes revolted. The Bush II administration also tried to revise these methods, with the same result.

The ACA stipulated the creation of a negotiated rulemaking committee that is based on the notion (and a statute) that you bring different stakeholders together to work on difficult issues, with the government agency in question (in this case the Sec of HHS) agreeing to use the solution developed by the committee as the new rule for how these designations are done if the committee can reach consensus. The idea is that interest groups will feel represented by the process and therefore accept the new rule (though there is no guarantee of this result).

Serving on the committee has been an interesting experience. It has been time consuming and complicated because of the many issues with which we have to grapple. At times it has been frustrating, yet I believe we are making progress toward an improved designation process.

However, regardless of the final outcome of our work, the highlight for me has been meeting people with different backgrounds from all over the country who are unified in a simple goal: to improve the health of those with poor access to primary care, and to improve the lives of those with unique health problems that would otherwise be unaddressed. Even when I have not understood the perspective or position of a colleague, or disagreed with someones position, I have never doubted their commitment to trying to best use the finite resources our nation has for these purposes in the best possible manner. And I have learned a great deal from these committed people. I am hopeful we will achieve a consensus by early Summer, when our work is to wrap up.

Here are my thoughts on the first two days of the January 2011 meeting.
September 2010 meeting day 1, day 2.
October 2010 meeting day 1, day 2.
November 2010 meeting day 1, day 2.


  1. Just wondered what you thought about this quote:
    Rep. Steve King of Iowa said it well: “Our guaranteed rights that come in our Constitution are diminished by the federal government deciding what health care we will have, what health insurance policies we’ll be able to buy, and what tests we’ll be able to take, and which doctors we’ll be able to go to. . . . It’s a cancer that eats away at us, and we’ve got to repeal it completely, pull it out by the roots so it doesn’t grow back again.”

  2. His quote is not based in fact. My grandmother has the ability to access the doctor of her choice BECAUSE OF Medicare

  3. What about the rest of us? Will doctor choice be a reality? Will doctors be bound by yearly analysis of your grandmpther's physical or mental abilities? What if Medicare payments slide? Will her doctor be willing to accept reduced payments? Something has to give to pay for these perks.

    What do you think about PM Cameron? Isn't he wonderful? Maybe the new Man of the Year if he can straighten out the bureaucratic nightmare socialistic style medicine created there?

  4. I have limited choice of doctor. I can only choose a Duke physician and then only the one whose list is open to new patients. These limits are imposed by my insurance. It doesn't particularly bother me, but it is a fact. You are correct that something has to give. What we need is to decide how much of the economy we are willing to redistribute via the federal govt. Then we have to raise enough in taxes to pay for what we say we want. If health care cost inflation doesn't slow, we will either go bankrupt or have taxes that are very high. As far the UK goes, we spend $2.15 per capita for each dollar they spend, and our health outcomes are quite similar. So, we got lots more to answer for than they do. They have constantly reformed their system the past 40 years. They are also far more honest than we are. For example, about 10% of folks in UK have private insurance and so can go to private hospitals and avoid waiting lists. I asked an English friend about this and he said 'we have a queen' we pretty much accept that everyone is not the same. Not saying we should copy them (in fact it wouldn't work) just that they are more honest in addressing limits.

  5. Your English friend is in a minority! The monarchy is impotent...a tourist draw. Most doctors in the UK have private insurance...the limousine left! :). It lives up to the name of the land of dirty sheets....another cost savings. Even the NHS wrote a report about this.

    The thing with the UK and Canada and others is...for lack of a better leech off us. They do not pay for research the way we do...but they gain from our research. I am pleased they can do this, but a true comparison of cost per patient isn't realistic when we pay for the test kitchen, and they get the recipe for free. But we get the prescriptions much sooner than they do. Our cousin just died a painful death there. First they did not order the test he needed, then when they did he had to go on a waiting list, then the NHS doesn't cover the chemo anti nausea drug (more savings per patient), then the end of life morphine via hospice was rationed. His family was grateful he died because of his terrific suffering. But...I'll bet his care and death were cheaper on the system than the typical American. Sigh!

  6. I am sorry about your cousin. Here is a series of posts written by Aaron Carroll an MD who blogs at Incidental Economist that addresses the general question 'where does the $ go' in the U.S. that is based largely off a report by Mckinsey Consulting. We do cross subsidize the rest of the world for pharma discovery, but that doesn't totally explain the difference.

  7. I agree, it wouldn't totally explain the difference. They have older equipment, you cannot get the newer meds, infection rates are higher, bad cancer cure rates because of these problems and the sad truth is if you die while waiting you are cost effective. My husband's whole family is still there. He visits a lot and lives in fear of getting in an accident while there. Once while visiting I had to go to the doctor. I looked down at the sheets (yes...real sheets that were not changed for what looked liked days) and there it was ....old blood and not just a few drops. They earned their name of the land of the dirty sheets.

    I will read the article later...but if I had to live there I would have private insurance. It is helpful, but people do not realize you still need the NHS with your private insurance, you do not get the government out of your hair just because you have private insurance.

    The media has painted a picture of socialized medicine that matches Dr. berwick,s romantic Jane Austen plan....but reality stomps the romantic out of most of us!

  8. Having everyone use a NHS GP is a brilliant move, because it means everyone has a stake in the system, even those who go private for secondary care. A question: they have a democracy, so why don't they scrap it? Why didn't Margaret Thatcher? She plus John Major were in power for 13 years in a row...I lived in Manchester for a time.

  9. My knowledge on Thatcher is limited. I would have to google it, and I am running late (when she was in power I was busy having a US hospital..thankfully....I believe 4000 British women gave birth last year in hallways, restrooms, etc, because the delivery rooms are busy).

    Off the top of my head Thatcher was a big free marketer (not the hell with everyone else Ayn Rand type...but..maybe a bit close...probably more lime Friedman)) and she encouraged the medical free market as best as she could. I think the Brits are proud of their healthcare and some live in denialism claiming it is a type of crown jewel. on.....wondering seems once socialistic medicine is implemented it is changed, but not foresaken? Which is why we do not want to go there here in the US. I cringe thinking about what my daughters cancer care would have been like in the UK (some cancers like breast amd prostrate have terrible rates compared to the US...and if you survive your treatment isn't the same. My daughter received a treatment still in research. The insurance company paid for the free market developed and sold privately treatment...that would not have happened in the UK where some people sell their homes and are forbidden to pay themselves. Their doctors feel terrible about giving them the news of prohibition...hence, Cameron's involvement).

    Free care will never equate with the free market. It limits choice, squelches innovation (realizing we are half way there with the government paying...but the government is doing a poor job and patients still benefit off our free market even when the taxpayers pay their tab).