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- Michael J. Wolk, MD, FACC, President, American College of Cardiology*
- ↵*Send correspondence to:
Dr. Michael J. Wolk, 520 East 72nd Street, New York, New York 10021
Like so many Americans, I am concerned about the economy and our war on terrorism both at home and abroad. National polls indicate that jobs and the economy consistently rank high among voter priorities (1), but health care is not far behind. And when it comes to health care, the issues facing the President and Congress in the years ahead are indeed daunting. For that reason, as the elections approach, we, as physicians, have a responsibility to familiarize ourselves with the candidates and their health care platforms and to make decisions on November 2 that will ultimately help guide our health care system toward a future that continues to value cardiovascular specialists and the care we provide to our patients.
On the campaign trail, President George Bush and Senator John Kerry both profess similar goals of high-quality, affordable, and accessible health care—sound-bites that will bring audiences to their feet across America. When examined closely, however, their words describe two vastly different visions for the country's health care system. Republicans see it moving from an era of employer-sponsored health insurance to a system that promotes consumer choice and responsibility and relies on the market to control health care costs while ensuring quality. Democrats remain rooted in the traditional employer-based group health insurance and government programs and intervention.
The Medicare debate is just beginning
Students of political history assert that second-term presidents have less ambitious policy agendas, reasoning that presidents seek to advance their most impressive policy proposals in their first term, always embracing another four years with cautious optimism. Acknowledging policy disagreements, few would argue that enactment of Medicare reform and a prescription drug benefit was one of President Bush’s most ambitious domestic policy initiatives during his first term. Also to his credit, Bush supported Congress in preventing three years of payment reductions to physicians, adding cholesterol screening and other preventive benefits to Medicare, and championing medical liability reform.
By enacting a Medicare drug benefit, President Bush effectively took Medicare off the table in this year’s election. Although a vast majority of Democrats discredit the new law and promise to overhaul it if given the opportunity, and some Republicans admit that it needs change, it is unlikely many candidates will discuss cutting Medicare. However, it is exactly this point that should concern physicians and other health care providers. Recent projections by the Medicare Board of Trustees show that the Medicare trust fund could run out of money before 2020 and that Part B costs will continue to increase faster than the gross domestic product (2). Congress will be looking for money, and physicians and hospitals are likely the first targets. Lawmakers could delay fixing the problems with the Medicare physician payment system or find a new and more unfavorable system for reimbursing physicians. We need candidates talking about Medicare, not just about adding new benefits and maintaining fiscal solvency but about adapting the program to meet the changing health care needs for seniors overall and ensuring that the system is fair and predictable for physicians.
The health system reform debate—it’s back
As much as elections serve as an engine for change, they frequently and, perhaps more realistically, lay the tracks that guide future debate on important policy matters. Candidates’ platforms reflect their political philosophies, and in 2004 the candidates competing philosophies are perhaps most stark in the area of health care system reform.
Making health insurance more affordable to the individual is at the center of Bush’s proposed health care policy initiatives. He proposes market-driven reforms that include the creation of tax credits for purchasing health insurance and the expansion of health savings accounts, as well as medical liability system reform, and the widespread adoption of health information technology (3). Although cost estimates vary, Bush’s proposed health care policy initiatives would cost upward of $70 billion over 10 years and according to the White House, would cover more than 11 million, and possibly up to 17.5 million, previously uninsured Americans (4). When set alongside Kerry’s $653 billion health care plan, Republicans seem to be asking themselves whether the President’s health care initiatives will be enough to satisfy voters in this election.
Majority Leader Bill Frist, the Senate’s only physician, unveiled his vision for the country’s health care system in 2014, which he laid out before an audience at the National Press Club in Washington, DC, two weeks before the Democratic National Convention (5). His proposals build on ideas generated by a 12-member Senate Republican health care task force and are grounded in the Republican philosophy of a consumer-driven system. Far more comprehensive than Bush’s platform, Frist lays out policy goals for universal electronic health records, a larger federal investment in prevention and public health, and health coverage for children and low-income Americans through existing public health programs, community health centers, and refundable tax credits. Frist wants to make the health care system more equitable for individuals who buy insurance on their own by allowing them to fully deduct, before taxes, the cost of their insurance, while limiting the tax exclusion employers now enjoy for providing health care benefits to their employees. Frist also proposes giving individuals and small businesses more purchasing power through purchasing pools and association health plans and allowing insurers to share risk more broadly by creating a so-called “Healthy Mae.” He even invokes the importance of personal responsibility by suggesting individual health insurance mandates.
The number of uninsured Americans now stands at 44 million, health care insurance premiums are on the rise, and more than 2 million jobs have been lost since January 2001 (4). These factors have given rise to a renewed interest among both Republicans and Democrats for advancing health care system reform. Still feeling the sting of the failed attempts at wholesale health care reform in the early 1990s, Democrats are proceeding cautiously.
The most extraordinary feature of Kerry’s health care reform plan is the magnitude of dollars he is willing to spend to ensure that 95% of Americans have health insurance, and he will do it incrementally and will pay for it by repealing much of Bush's tax cuts. Essentially, he is giving voters a chance to choose between tax cuts and a nearly universal health insurance system. But Kerry’s health care plan is far from the radical universal health care schemes of the Clinton era. He favors an expansion of government programs for the poorest children, adults, and families (6). The hallmark of Kerry’s plan, however, is his reliance on group health insurance. Kerry proposes creating a new group insurance pool within the Federal Employees Health Benefits Program (FEHBP) that would be open to all individuals and large and small employers. Like Bush, Kerry also calls for tax credits targeted toward small businesses, those ages 55 to 64 years, and workers between jobs. The credits would be usable for buying into this new pool, dubbed the “Congressional Health Plan.”
Rising health care costs rank among the top concerns of businesses, both large and small. From 2002 to 2003, employer-sponsored health insurance premiums increased nearly 14% (7). To protect businesses from rising health care costs, Kerry would reimburse employer health plans for 75% of catastrophic costs incurred above $50,000. To be eligible for the rebate, employers would be required to provide “affordable” health insurance for all of their workers. This is where the differing philosophies come to bear. Kerry would have the federal government take over the high costs for employers, whereas the Frist proposalrelies on the private market to manage the costs of high-cost enrollees. Will insurers and businesses be concerned that a government-financed employer subsidy, such as proposed by Kerry, could lead to government regulation of health benefits? Kerry’s policy staff dismiss the notion that his solution is a back door to increased government oversight and, instead, offer it as a way to lower premiums, prevent adverse insurance marketing, and protect employer-based systems without resorting to a full government takeover of the health care system.
Medical liability reform and the great partisan divide
Democrats and Republicans do find themselves in agreement in areas such as the need for better and widespread use of health care information technology, including electronic medical records and quality improvement and efficiencies, such as disease management, in health care delivery. However, although they agree that the rising cost of medical liability insurance must be curbed, Bush and Kerry find themselves divided on the issue of capping the amount of non-economic damages that can be awarded in medical malpractice cases.
A cap on non-economic damages is the one reform that has proven to control the growth of medical liability premiums (8). And although a cap on non-economic damages alone is unlikely to be enough, any solution that dismisses the need for caps is a non-starter with the physician community. Kerry and running mate John Edwards blame the insurance companies and offer a solution that would eliminate the “special privileges” that allow insurers to fix prices (9). However, no evidence of collusion in the marketplace exists, and because states are already required to reject rates that are excessive, inadequate, or unfairly discriminatory, the physician community does not believe that doing away with these so-called special privileges by amending a 1945 law, commonly known as McCarran-Ferguson, will have any effect on lowering liability premiums.
The American College of Cardiology (ACC) agrees with Kerry and Edwards that physicians should spend more time with patients and less time in the courtroom, that personal injury lawyers must be held accountable, and that frivolous lawsuits must be stopped before they reach the courtroom. Instituting caps on non-economic damages and reducing the amount of money that flows directly into attorneys’ pockets, as Bush proposes, is one way to cut down on cases without merit. Kerry and Edwards offer a solution that would send all claims before a “qualified medical specialist” to make sure a reasonable grievance exists. Although the idea is laudable, mechanisms need to be in place to ensure that the medical expert witness testimony is accurate. To this end, the ACC is committed to addressing the issue of medical experts as part of its overall ethics agenda.
Our elected officials must find a way to not only provide citizens with affordable health insurance but also to control rising health care costs. They must create a health care environment that continues to attract new and highly skilled physicians by reforming our medical liability system, offering fair reimbursement, and minimizing burdensome regulations. They must ensure that our health care system continues to evolve by encouraging the use of new treatments and technologies, rewardingthe delivery of high-quality care, and providing incentives to incorporate health information technology into our hospitals and practices. And they must dedicate the resources necessary to save lives through public health education and outreach.
Three years ago, the ACC decided to form a political action committee (PAC). The purpose of the PAC is to support elected officials and candidates who champion the causes of the cardiovascular community. However, it is voters who ultimately wield the most influence. This November, physicians must vote and play as large a role as possible to advance what is best for their patients. If we do not make health care our number one concern at the polls, then how can we expect our elected officials to make it their top priority?
A special thanks to Camille Bonta, Director, Legislative Policy, ACC, for her assistance in preparing this article.
- American College of Cardiology Foundation
- ↵2004 polling on the most important issues facing the nation. National Journal. Available at: http://www.nationaljournal.com. Accessed August 6, 2004.
- ↵2004 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, March 23, 2004. Available at: http://www.cms.hhs.gov/publications/trusteesreport/2004/tr.pdf. Accessed March 23, 2004.
- ↵Policy memo: health care and the middle class, June 16, 2004; http://www.georgewbush.com/HealthCare/Read.aspx?ID=2777. Accessed July 29, 2004.
- ↵Fact sheet: President Bush’s plan to make health care more affordable. Office of the Press Secretary, the White House. Available at: http://www.whitehouse.gov/news/releases/2004/09/20040902.html.Accessed September 2, 2004.
- ↵Frist W. Senate Majority Leader Frist delivers remarks at the National Press Club. FDCH Transcripts, Congressional Events, July 12, 2004.
- ↵A plan for stronger, healthier families and children. Available at: http://www.johnkerry.com/issues/health_care/family.html. Accessed July 29, 2004.
- ↵Employer health benefits 2003 annual survey. The Henry J. Kaiser Family Foundation, September 9, 2003. Available at: http://www.kff.org/insurance/ehbs2003-1-set.cfm. Accessed August 10, 2004.
- ↵Addressing the new health care crisis: reforming the medical litigation system to improve the quality of health care; U.S. Department of Health and Human Services, March 3, 2003. Available at: http://www.hhs.gov. Accessed March 3, 2003.
- ↵John Kerry and John Edwards have a real plan to lower health care costs. Available at: http://www.johnkerry.com/pressroom/releases/pr_2004_0719a.html. Accessed July 29, 2004.