Some Thoughts on What’s Ahead

David U. Himmelstein, M.D., Steffie Woolhandler, M.D., M.P.H.

The Situation We’ll Face After November 6

A - No matter who wins the presidency, the main events in health policy for the months ahead – impacting the vast majority of Americans – are:

1- A new surge of corporate takeover of health care delivery under the guise of ACOs, including mergers and acquisitions of hospitals and group practices, and the rapid transition of physicians into employee status.

2- Medicare and Medicaid privatization and cutbacks.

B - The problem of uninsurance will be modestly improved by the ACA.According to the latest CBO estimate 36 million will remain uninsured.Yet the safety net institutions that care for the uninsured are facing substantial cuts, leaving few resources to care for the legion of uninsured.

C – Underinsurance will continue to grow as a problem, compromising access and endangering the financial health of many in the middle class.

D- The mounting wave of consolidation will leave most communities with only a handful of provider organizations, many with only one.In this context the rhetoric of market-based efficiency is gibberish.

The deteriorating state of U.S. healthcare will generate growing dissatisfaction, which is likely to be temporarily muted in the immediate post-election period if Obama is re-elected and implementation of the ACA proceeds, raising hope that better is ahead.Such hope will fade quickly after January, 2014 as Americans face the reality of the reformed health care system.

PNHP’s Role

A – We must speak to the day-to-day experience of progressive practicing doctors, rallying them to defend access to care, but also the soul of our profession as we’re pressed to act and think like corporate middle managers beholden first to our employers.

B – While patient experiences of profit-driven ACO abuses will eventually come to light, physicians are uniquely positioned to sound an early alarm about practices such as:

1- Gaming of risk adjustment through cherry-picking and upcoding.

2- Incentives to physicians that conflict with patients’ best interests, e.g. financial rewards for minimizing referrals,or penalties for recommending/approving out-of-network care.

3- Efforts to exclude unprofitable patients and the physicians who care for them.

An emerging pattern of such practices, together with examples of patient harm, would provide a valuable antidote to ACO infatuation.

C- We should embrace the positive kernel of the ACO idea – teamwork, coordination, the avoidance of excessive intervention – but reject the “poison pill” of risk sharing because it pits providers against patients.We must demand that ACOs spend all of their budgets on care and not be allowed to reward executives or providers for financial success, or retain unspent funds as profit or (for non-profits) surplus.Without this restriction ACOs that bend care to profitability will thrive, while those that put patients first will fail.

D- As provider monopolies emerge we should demand public oversight and even control of the dominant provider organizations in our communities.Such oversight must go well beyond the phony accountability of “quality monitoring” to include community control of resource allocation (a vital determinant of community health) – and perhaps even public ownership.

E- We must spotlight the ongoing grave access problems of the uninsured, documenting their stories and efforts by some institutional providers’ to evade responsibility for their care.Defense of safety net hospitals and clinics is a top priority in the short term.The sharp cuts to Medicaid proposed by Romney/Ryan would greatly increase the ranks of the uninsured and destabilize the finances of the safety net; the murderous consequences of such cuts must be exposed.

F- Similarly, the growing problem of underinsurance should be highlighted in the starkest terms.

G- Our response to the drive for Medicare cuts and privatization should highlight:

1- The fact that privatization is a major cause of Medicare’s financial woes.

2- The grossly inadequate coverage that Medicare currently offers to middle income seniors, a problem that would be exacerbated by cuts.

3- The far better coverage for seniors that would be feasible under single payer.

H- Of course, we must continue vigorous support for HR 676 and, in states where a local single payer drive is viable, state-based legislative efforts.