The vote heard around the USA: Putting the brakes on health care reform legislation

Douglas W. Jackson

The Senate voted on Christmas Eve. It had not done that since 1895 and the issue then was federal benefits for U.S. servicemen, which was hardly contentious compared to the current health care legislation. The increasingly unpopular health care reform bill that was emerging from the Senate was based on cajoling; rushing the proposed legislation through the chamber to quell any debate; and giving away appropriations, perks and favors to special interest groups to buy the needed support for the magic 60 votes that would have ensured its passage.

If the Senate bill had been reconciled with the House bill, it would have been the largest expansion of the federal spending for health care since the creation of Medicare. The 60 votes that would have enabled overriding a Republican filibuster in the Senate required much old fashioned horse trading using behind-the-scenes, pork-laden deals by Senate Majority Leader Harry Reid (D-Nev.).

After the historic Dec. 24 vote, former White House Deputy Chief of Staff Karl Rove summed it up by saying he wasn’t aware of any senators who didn’t have something in the bill that was important to them.

However, the voices of the people were able to do what we in health care could not. Through an unexpected turn of events in Massachusetts, the voters sent a message to the president and the lawmakers who were intent on rushing this legislation through Congress to slow down.

Fortuitous events

The 60-vote total would have been made possible by a series of circuitous events: Sen. Arlen Specter’s (D-Pa.) conversion to the Democratic Party; Sen. Al Franken’s (D-Minn.) finally being declared the winner of his seat by a narrow margin; and the anticipated takeover of Sen. Kennedy’s (D-Mass.) seat by a Democrat through the Massachusetts legislature changing state law.

Ironically, it was the dark-horse victory of Republican Scott Brown to fill Sen. Kennedy’s seat that busted the filibuster-proof Democratic majority. The independent voters in the staunchly blue state had clearly voiced their concerns over the course that health care reform was taking. In addition, it made many of those up for re-election scramble to cover their voting record.

If the final version had passed and been signed, one question would have remained: Could the Democrats convince the American taxpayers the additional costs would be worth it?

Campaign promises

The message of “hope” expressed during the presidential campaign was in anticipation of reforming a chaotic health care system. The reform proposed would not only increase access to affordable, quality health care for all Americans, but also, reduce unnecessary costs and halt the rising overall costs of health care.

However, the reality was the new Senate bill would have only insured 7% more Americans and numerous health care leaders and economists expressed their doubts that it would restrain costs. In fact, the final bill would have most likely accelerated health care spending.

The people of Massachusetts fortunately knew that you cannot get more for less. The true costs of this attempt at health care reform had been cleverly disguised from the public. The funding proposed was much like a pyramid scheme with deferred payments. It depended heavily on those entering the game later having to pay many of the real costs.

It was frustrating to watch and listen daily as the opportunity for real health care reform was traded away in the House and then the Senate in order to pull together the votes necessary just to pass something … and pass it quickly.

Where was medicine’s voice?

During the time it took to pass a bill in each house, did you hear the strong voice of the medical community speaking out for the good of its patients? Neither did I, mostly because it didn’t happen in an effective manner. Once we realized we were going down the wrong path, organized medicine should have spoken up in opposition to some of the proposed changes. If it had passed we would be trying to modify and change it for years, in addition to having to pay for all of the ramifications.

During the debates, it became apparent the American Medical Association (AMA) had diminished impact and was not the voice of the medical profession it once was. Democrats touted the AMA’s early blanket endorsement of the House version of the new health plan, but little mention was made in the press coverage concerning the opposition by the American College of Surgeons and 18 other specialty groups, including American Academy of Orthopaedic Surgeons (AAOS).

I was not alone in believing that the AMA endorsement was given too early to the Democrats. It was used to give credence to Pelosi’s maneuverers. Unfortunately, there is confusion in the public’s perception that the AMA still represents their physician and the Democrats used it to try and gain further acceptance for the legislation in the House.

Who is the AMA?

The AMA is America’s largest physician organization with approximately 250,000 members. It is a shell of what it once was. It has become an umbrella group that tries to interact and collaborate with about 180 medical societies at differing degrees. The AMA will not disclose the number of the actual dues-paying members who are practicing physicians — leaving out residents, interns, those who have retired and those in the military. Published estimates from 2005 noted that about 135,000 of the overall 244,000 members were actual practitioners.

Nonmembers, like me, still do not know why the AMA signed off early. I wonder if it had anything to do with a promise to stop the scheduled 21.5% cut in physician reimbursements that was to occur in January 2010 and another 2% every year after that under a formula known as the sustainable growth rate (SGR).

The politicians then pulled another “Ponzi” scheme by moving $210 billion fiscal automatic cuts in Medicare payments to doctors from health care reform over to the general tax obligation — done to keep the health care reform under the a trillion dollars.

I believe the reimbursement cuts would have been blocked even without the AMA’s early endorsement because enough of the practicing physicians would stop seeing Medicare patients or significantly decrease their volumes of this payer group. The legislators were not willing to withstand the heat from patients if that was to occur at this time.

Meaningful influence

Even if all physicians were organized, our lobbying influence is limited due to a lack of funding and the small voting blocks we represent. Since the 2000 election cycle, the AMA’s political action committee has contributed $9.8 million to congressional candidates, according to data from the Federal Election Commission and the Center for Responsive Politics. Prior to 2008, Republicans out-received the Democrats for four election cycles. In 2008, 56% went to Democrats. Yet, this is small in comparison to other sectors of the health care industry, which have spent more than $250,000,000 in one quarter on specific issues.

We will see history made one way or another as the leaders of the House and Senate bring forward a more incremental approach to reform. The rush to have a plan before the president’s State of the Union address in late January was not achieved. The Democrats are bracing for the fact that the final version of this legislation will need a more bi-partisan approach as the 60 vote majority will not be there and many house seats may be in jeopardy as voters have been awakened by the shot heard from Massachusetts.

We will most likely remain spectators in these deliberations, but hopefully the voice of medicine has also been roused by the people of Massachusetts and we will have more input and not sign off as early and easy.

Douglas W. Jackson, MD
Chief Medical Editor