Could It Be That (Gasp!) The System Works?

By  |  March 20, 2010 |  11 

Heading into the final weekend of Mr. Toad’s Wild Ride, who could have guessed that in a year that brought us Death Panels, Pickup Trucks, “You Lie”, The Cornhusker Compromise, Bart Stupak (boy, that must have been a tough name to grow up with), and the Senate Parliamentarian-as-Rock-Star, we would be on the cusp of passing a perfectly acceptable healthcare reform bill, a once-in-a-generation legislative achievement.

Unmistakably, the mojo has shifted back to the Democrats – it is amazing how a dour and monolithic opposition can cause even Dems to unite for a common cause. Our President has also learned a few lessons, including the importance of symbols, populism, and singing with one’s diaphragm. (We knew we were in trouble a few weeks ago when Rahm started being criticized for not being sufficiently Machiavellian.) With yesterday’s CBO figures showing that the reform plan will save nearly $150 billion, even fence-sitting Democrats now see more political risk in saying No than Yes. That, of course, is the most relevant calculus, and with it more and more of the Blue Dogs are entering the Yes column each day.

The politics were fun enough, but the thing that’s most remarkable is this: The legislation that now seems likely to pass ain’t bad. To an impressive degree, the crazy deals, the budget sleights-of-hand, and the extremist positions have been or will be stripped out of the final text. The bill will manage to cover most uninsured Americans. Its new revenue streams are not magical: higher taxes on wealthy Medicare recipients, some take-backs from generously funded Medicare HMOs, and some (watered down to keep the unions in line) new taxes on “Cadillac” health plans. The most heinous aspects of the under-regulated insurance system – particularly the exclusions for preexisting conditions and the possibility of losing insurance after becoming ill – will become memories of a crueler American past, like slavery and McCarthyism. 

Not perfect, you say? Sure, the legislation is not perfect. Not everyone is covered. The problems with the malpractice system remain largely unaddressed. Hard decisions about promoting quality, safety and efficiency are kicked down the road. Lots of newly insured people won’t be able to find a primary care doc. Care will remain fragmented and chaotic for the foreseeable future.

But even in these areas, the winds are blowing in the right direction: support for comparative effectiveness research; experiments with bundling, Accountable Care Organizations, and Medical Homes; promotion of improved transitions; malpractice pilot studies; a small dose of steroids for MedPAC.

And maybe, just maybe, a renewed sense that Washington can tackle hard problems.

Even the most infuriating examples of demagoguery may have silver linings. The whole Death Panels thing made me ill (particularly when I learned that Governor Palin supported legislation to promote end-of-life discussions in Alaska precisely one year before she went on her cynical Death Panel tirade), but the topics of rationing and how we approach end-of-life care are crucial and really sticky. When we return to them, as we inevitably will, we’re likely to have less heated, more thoughtful discussions, having gotten some of the craziness out of our system this time around. Just think about the tenor of today’s public debates over legalizing pot, gays in the military, and stem cell research – the topics remain lightning rods, but the discussions are much more civil and thoughtful than those of a decade ago.

All in all, the legislation being considered this weekend is sufficiently reasonable and centrist that it can resist the playground name-calling (“Socialist!” “Government Takeover!”). The fact that it has no chance of attracting a single Republican vote speaks volumes about cold political calculation, and relatively little about the nature of the changes the bill will usher in. This is, in fact, a bipartisan bill – one that deftly splits the difference between lefties who want Single Payer and massive government involvement, and righties who want to “keep Government out of my Medicare!”

Watching the process was nauseating, but if I could have gone into a deep sleep after the Obama election and awakened this weekend to find Congress passing the bill it is now considering, I would have said, “Hey, that’s not too bad.”

Unfortunately, I stayed awake for the whole thing, and I may never eat sausage again. But that doesn’t change the outcome.

Or the fact that the system, to a remarkable degree, worked as the Founding Fathers hoped it would.


  1. gene spiritus March 21, 2010 at 4:22 am - Reply

    In the last 24 hours it was great to see both CHA and the University of California Office of the President come on board and support the bill. I agree with you that the bill is a great start and it gives us an opportunity to improve health care for many.

  2. Brian Clay, MD March 21, 2010 at 3:31 pm - Reply

    I am cautiously optimistic. It is refreshing to see that this legislation makes significant inroads into expanding coverage, which will likely (if the Massachusetts experience is an accurate precedent) bring the issue of needing to expand and support primary care front and center. Of note, this can only be a positive thing for hospital medicine, since the work of improving and optimizing transitions of care is certainly more useful in a world where there is reliably a next-provider-of-care to transition the patient’s care to.

    I do worry about the long term financial issues with the solvency of Medicare; although there is support for MedPAC and comparative effectiveness research, the major approach to reducing inpatient costs is likely to come in the form of bundled payments, which, to a degree, outsources the hard decisions of cost-reductions to an arena where physicians may fight amongst themselves.

    That said, I’m glad we’re starting this now while I still have 30 years or so of medical career left in me. I will get to see what we end up with on the other side.

  3. chris johnson March 21, 2010 at 5:47 pm - Reply

    The most important thing to me is the precedent the bill sets — that healthcare is a public good, not just any old commodity. Once we’ve accepted that, deciding the best way to regulate and distribute it is much easier to accomplish.

  4. Jack Percelay March 21, 2010 at 10:23 pm - Reply


    Insightful comments as always. Interested to hear what you’ll have to say in DC 3 weeks from today.

    Agree that the process has been very disappointing, but I am cautiously and/or naively optomistic that now that principles of universal coverage are now the law of the land, more rational debate might take place.

    Ideally middle of the road democrats and middle of the road republicans would now work together to create improvements within this new framework. Name calling and finger-pointing are more likely in the Fall elections.

    CMS and other regulatory bodies are likely to sponsor more reasonable debate and dialog, and we should all be proud that SHM has established an effective working relationship with these agencies and has a track record of being a meaningful and worthwhile partner.

    The legislation is NOT perfect. There is much work still to be done. We are willing, ready, and able.

    Jack Percelay

  5. Bob Wachter March 22, 2010 at 3:13 am - Reply

    With the remarkable passage of the healthcare bill tonite, here’s my prediction: a surge in popularity for Obama and the Democrats, with more and more pressure on the Republicans to say something more than “Hell, no.” And, if we are lucky, we’ll see internecine warfare on the far right, with the emergence of a centrist wing more interested in effective governance than the politics of negativism.

    How could this happen? History does repeat itself: the Democrats got clobbered in the Clinton I midterms after the failure of several big reaches, particularly gays in the military and healthcare reform. But then came Republican overconfidence, Gingrich’s Contract with America, the shutdown of the government, and ultimately the rejection of the Republican’s negativism as Clinton finally found his voice.

    With tonite’s vote, I think Obama may have short-circuited this process. The Dems will probably lose some seats in November (as the party in power nearly always does), but my guess is that this win (coupled with an improving economy) will markedly mitigate the harm.

    We’ll see. In any case, it’s nice to dream…

  6. Jim Shanahan March 25, 2010 at 12:33 am - Reply


    There is a larger civics issue here that, somewhat incredibly, was not adequately debated during the year-long health reform effort. That is, are we prepared for the effects of setting the precedent that the government has the power to require citizens purchase a specific product as a condition of life? Its a precedent that really is a Rubicon. The question that follows is, why just limit this power to healthcare? Healthcare is important to me and to you, but everyone has their different issues and enthusiasms. That’s why there are so many lobbyists. There are endless possibilities for what could be required of us, from the mandated-purchase perspective. Why not books, or other items that aid mental as opposed to physical health? For that matter, why not mandate the purchase of a product produced by a company owned by one of my campaign contributors? (Being from Chicago, it wont surprise me a bit to see this happen.) In time we might find ourselves living under dozens of purchase mandates. Yes, its still different from a religion mandate. But not so different that it should escape broad public debate and acceptance. For all the good that may be done by providing access to the system for millions of previously uninsured, we can’t overlook the civic damage that may be done putting this new precedent and new power into the hands of ambitious professional politicians. Once we go there, there is no going back. Have we adequately debated that?

  7. Bob Wachter March 25, 2010 at 3:42 am - Reply

    Thanks, Jim — this is the classic libertarian argument, and we’ll have to see how this gets litigated. I’m reasonably sure it will hold up in court.

    It’s not like there is no precedent for this level of government mandate. I need to wear (and buy) a seat belt, and auto insurance… But I don’t need to buy life insurance, or a Tall Mocha, or an iPhone. One of the jobs of civilized society is to carefully figure out where to draw these lines.

    Why should healthcare insurance coverage be on the “you must have it” side of the line? Because your “personal” decision to go uncovered isn’t costless to me. As a society, we have decided that your lack of insurance won’t bar you from getting seen in the ER, or going to the ICU, or getting a liver transplant. If you’re uninsured, this means that the rest of us pay for your care, and so we have a powerful interest in persuading you to be in the coverage pool. Or, if you choose not to (which you’re free to do — you won’t get arrested under the new bill), to contribute to the commons to cover the costs of your private decision.

    Of course, we could do this another way. Just think, you don’t have to contribute to a retirement fund, but you do have to contribute to Social Security. In other words, there’s a government mandate to create a government-run pension plan for retirees. Good thing or bad thing? I believe it’s a good thing.

    And so might be forcing everyone to contribute to their healthcare through their taxes, which is precisely how every other country handles this issue (and how we handle funding healthcare for older Americans, through Medicare). But that’ll have to wait another day, since we hate our government and want to keep this activity in the private realm. So be it, but then we need to force everybody into the coverage pool, lest the problems of Free Riders and Adverse Selection really screw up the system.

    In terms of the politics, I’m with you — the “individual mandate” wasn’t as heavily debated as I might have expected; it was hijacked by Death Panels, the Public Option, and several other hot button issues that seemed to resonate more deeply. We’ll see what happens once the mandate becomes tangible; I suspect it won’t be a huge deal, as long as the insurance is semi-affordable. But you never know.

  8. Brian Clay, MD March 25, 2010 at 4:25 pm - Reply

    Although the auto insurance analogy isn’t perfect, it’s fairly close.

    The notion of “cost-shifting” between different insurance payors and the advent of EMTALA legislation effectively made citizenship and existence in the United States a potential cost to other citizens, as random, unpredictable, and high-cost injuries and illness could befall any person at any time.

    The libertarian argument does not work in health care unless the arguer swears to forgo any taxpayer assistance in the future, even if one of the above calamities should occur, or if society decides to deny emergency medical assistance — under any circumstance — to persons who have elected not to purchase medical insurance.

    I am certainly not a big fan of where a slippery slope evolution of government say on our personal actions might go (“Sir, I’m going to have to ask you to step away from the nachos”); however, I find it difficult to accept the argument that persons, who are young (for now) and healthy (at least in part due to good fortune) can defer participating in the risk spread until later on, when they themselves have medical needs.

  9. James March 29, 2010 at 9:11 pm - Reply

    Be careful quoting the CBO numbers, as anyone with knowledge of the fiscal note scoring process knows they are classic “garbage in, garbage out” scenarios. For example, if you count ten years of revenues to pay for six years of benefits, you likely come out ahead. But, what happens when you have to pay for a full ten years of benefits? Also, $371 billion was lopped off the top by having the “doc fix” for Medicare carried as a separate bill to come later. So, “savings” are counted in today’s bill that are going to be taken away later. Be for or against the bill, but understand that the fiscal impact numbers were fudged.

  10. Andrew Bailey, M.D. March 31, 2010 at 2:21 am - Reply

    We shall see, time will tell…..

  11. Andrew Bailey, M.D. March 31, 2010 at 2:40 am - Reply

    Yes, the Process to passage of ObamaCare has been illistrative of The System, to be sure.

    One Democrat “no” vote was converted to a “yes” vote when his brother was appointed as a district judge.

    Two Democrat “no” votes were converted to “yes” votes when the Democratic legislature permitted increased water flow to their central valley farmland, temporarily ignoring environmental concerns in lieu of an immediate benefit to the constituency.

    One Democrat “no” vote was converted to a “no vote at all” over an ethics charge regarding sexual improprieties. No Democrat is ever forced out of office because of sexual improprieties, until now.

    Other key Democrats were threatened with ethics investigations by the Pelosi panel.

    Opponents of the bill have been accused as racist fascist homophobes and sexual perverts (the meaning of the term “tea bagger”).

    Candid discussions such as occasionally show up in obscure podcasts made by medical policy wonks give a glimpse into the reality of the process. May I paraphrase from last summer’s ACIM podcast on healthcare policy: “Any effective universal medical system requires that healthcare is rationed and restricted by a central authority. The trick is to hide this objective from the public until the changes are law and then it will be too late to repeal it.”

    As I said, we shall see as more and more Americans understand just what the Democratic congress has passed. It’s possible they may grow to like the thing.

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About the Author:

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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