Editor's Note
The Next Round for Reform
Political change in this country is a messy business. Since July 4, 1776, the engine of democracy has spitted and sputtered, sometimes reversing, sometimes grinding to a near halt in the quest to refine what our Founding Fathers initiated. Perhaps no issue has had more false starts than health care reform. Unfulfilled promises for health care reform have plagued most presidents since FDR, with the exception of LBJ, who muscled the bills that created Medicare and Medicaid through Congress in 1966. President Clinton rode into Washington in 1992 sensing an apparent mandate to change the system and watched as his wife orchestrated a much-publicized, much-criticized failed effort.
Last March, it seemed that President Obama had broken the spell. With its provisions for an expansion of the Medicaid population, guarantees of insurability that would result in an additional 32 million Americans with health insurance, and innumerable proposals for experiments in patient care delivery, the Patient Protection and Affordable Care Act (ACA) was the most ambitious foray into health care reform since LBJ’s armtwisting victory in 1966. To the dismay of his liberal supporters, Obama achieved passage of the ACA through compromise after he lost his filibuster-proof majority when Massachusetts, in a moment of political irony, replaced the deceased, longtime single-payer proponent Sen. Ted Kennedy with a conservative Republican. Conservatives were even more dismayed. Before, during, and after the November 2010 elections, criticisms of the ACA in the press and from all along the political spectrum mounted. Trouble was brewing.
The ACA has become public enemy No. 1 for Republicans. The Republican-dominated House has attempted to repeal the entire bill with passage of the largely symbolic “Repealing the Job-Killing Health Care Law Act.” Their next anti-ACA strategy likely will involve picking off individual parts of the bill. Attorneys general in many states have initiated lawsuits challenging the constitutionality of the ACA’s health insurance mandate, and at least one federal judge has ruled in their favor. Although the ACA likely won’t disappear, it seems that changes are afoot.
So this seems like a good time to revisit the issue of health care reform. Already, we’re seeing that regardless of what happens to the ACA, new experiments in delivering care will continue to pop up like spring tulips. With them, we will learn a whole new set of acronyms such as “ACO.” And we will likely have to confront the truly difficult questions about how much we do for people at the end of life.
The wrangling and machinations in Washington and at state capitals will grind on. Test cases will wend their way through the courts perhaps going as high as the U.S. Supreme Court. And, unfortunately, many of the root causes of our ongoing health care dilemma will get buried in the fitful mess that is American politics. Yet no matter who’s in power, there’s a fundamental conundrum that needs clarification: How do we spend less for medical care without sacrificing quality?
Charles R. Meyer, M.D., can be reached at cmeyer1@fairview.org.