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November 03, 2010

Swing to the right: The election and its effects on health reform

Like Tom Friedman, who lampooned some of this year's unreasonable campaign rhetoric in a recent column, I too would be in favor of reality-based political campaigns ... but that seemed to be too much to ask for this year.  Instead of truth, we now have truthiness.  The joke news shows (and their joke political rallies) seemed to be more popular than the evening news.  (I wish Jon Stewart and his 200,000 fans on the Washington Mall last weekend had stayed home, canvassing for their candidates of choice.)  Fact-checkers told us that many political ads this season were in the "barely true" or "pants on fire" zones according to the Truth-O-Meter.  But in the end, the buzzwords seem to have worked their magic, and many "insiders" are out, and "outsiders" are in.  The angry and the impatient on the campaign trail have, in some cases, adopted the line from the movie Network: "I'm mad as hell, and I'm not going to take this any more," perhaps forgetting that while that line garnered the Howard Beale character strong ratings, network bosses arranged for his on-air assassination when his ratings fell.

The Utopia tune at the top of this post, "Swing to the Right," comes to you from the Ronald Reagan era, and perhaps we are seeing the generational swing of the pendulum back to the right.  It does seem to happen every 30 years or so ... but don't blame me -- I'm from Massachusetts (home to a Democratic sweep this Election Night).

The last two years have seen a tremendous amount of change in Washington.  The question of the moment, of course, is:  How will the election results affect implementation of health care reform?

The short answer is that even having sustained the losses that they have, the Democrats in Congress will be able to sustain a Presidential veto of any GOP anti-health reform initiative.  The 2012 election may well determine the ultimate course of health reform.  If the GOP gains further ground in two years, then implementation may be that much more difficult to accomplish.

For a cogent analysis of the high stakes for health reform in the midterm elections, see Henry Aaron's recent piece in the New England Journal of Medicine (hat tip: Jane Sarasohn-Kahn, aka @healthythinker).

(As an aside, the challenges to the health insurance mandate pending in courts around the country, of course, also pose a potential threat to health reform implementation.  Interestingly, GOP opposition to the health insurance mandate coexists with support for the spread of affordable health insurance for individuals, even though combining the two positions makes no actuarial sense: without mandate-driven health insurance purchases by Young Invincibles, there can be no "affordable" health insurance for individuals in a community-rated market.)

Stay tuned for the next bit of political theater as the latest "doc fix" expires December 1, and the lame duck Congress decides what to do about the SGR and the nearly 25% Medicare physician fee schedule cut that will go into effect unless, once again, there is some last-minute Congressional action.

Update 11/5/2010:  Here's a better link to the 2007 MedPAC report, "Assessing Alternatives to the Sustainable Growth Rate System," and a link to the Congressional testimony given on the MedPAC SGR report by Glenn Hackbarth.  It's remarkable to consider how many elements of MedPAC's recommendations made their way into the ACA, while the SGR formula was left alone.  As we move forward into the realm of bundled payments and quality incentives (Massachusetts is getting there first), capping FFS inflation is just not where we ought to be focusing our energies.  Here's hoping that when Don Berwick and Kathleen Sebelius get hauled in to testify at lots of Congressional committee hearings next year they get to put a bug in the ears of the legislators about this issue so that a long-term solution to the SGR issue may be implemented that will be consonant with the way the rest of the health care market is headed.   

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


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Great writing here David and thanks for shedding some light on this in a timely fashion!

I'm on doc fix death watch due to consulting I do -- so what's your guess as to what the Republicans will do in that regard. Really try to block it because they are all for less govt. spending and Dems can't figure how a way to come up with the cash to cover it? Not a way to make friends in the medical community. This issue is so contradictory because generally Republicans are on the side of those in the upper tax brackets, but only when they are running some other kind of business than being a medical professional, apparently. YOu know the cut is predicted to be about 30 pct on Jan 1st (compared to current CF), the 25 pct is only for December.


This is a fun piece, but it's a bit shallow on the implications of the Republican's landslide victory in last week's mid-term elections, and the possible implications of their new-found control of the House of Representatives.

The House that controls appropriations and funding for the Affordable Care Act, and the Boehners will almost certainly try to use this "stick" to eviscerate large swaths of the health reform law. They don't need the Senate or the Big O to do this.

The worst case scenerio for those of us who support the law w/b if the Boehners went after the individual mandate (which they are likely to do on grounds that it's an affront to personal liberties or whatever). This is the part of the law that allows insurers to spread the costs among sick and healthy, which is the only way insurance can work. Without the individual mandate, and with other parts of the law left intact, Medicare, Medicaid and yes, the Private Insurers too, are going to be left with a very sick pool of patients and no way to stay afloat. That would be very bad!

If interested, please read more here:

Glenn --

I agree; the battleground now shifts to the House, and the battles will center on appropriations and potential amendments to the ACA at the margins. The individual mandate question will end up being decided in the courts -- though of course it's a critical element of the broader plan, needed to cross-subsidize community-rated coverage for other folks. Thanks for the link to your post.

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