The global economy is on life support, unemployment is marching upward, wars rage on in Iraq and Afghanistan, and the federal deficit is approaching $1 trillion. By necessity, President Obama will push campaign promises to lower healthcare costs and provide affordable, accessible health insurance to all Americans to the end of his “to do” list, right?
“If we want to overcome our economic challenges, we must also finally address our healthcare challenge,” Obama said in a Dec. 11, 2008, speech in which he nominated former Sen. Tom Daschle (D-S.D.) to be his secretary of Health and Human Services and appointed him director of a new White House Office on Health Reform.
What this aggressive pursuit of healthcare change means for hospital medicine is still unclear, say health policy experts and hospitalists, because the Obama administration’s plan isn’t concrete and will change as it moves through Congress and the forums of public debate. Even so, some experts think an Obama healthcare overhaul would mean more revenue and information technology advancements for hospitals as well as significantly more patients as millions of newly insured Americans flood a system beset by a dwindling number of primary-care physicians.
For hospitalists and other physicians, the Obama plan could mean:
- Access to more information on what therapies work best for patients.
- A focus on preventative care.
- Greater emphasis on care-management programs and medical homes, especially for people with chronic conditions.
“He will lay out a bold vision on what he wants to do over time, and then he will enact it in several steps,” says Karen Davis, PhD, president of the Commonwealth Fund, a private healthcare research organization. “He’s certainly said it won’t be business as usual.”
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Obama says he will work immediately to expand eligibility for the State Children’s Health Insurance Program (SCHIP) and, in light of the recession, direct more federal money to states’ Medicaid programs, says Joseph Newhouse, PhD, a professor of health policy at Harvard University. Indeed, in the months before she was named deputy director of the White House’s new office on health reform, Jeanne Lambrew urged Congress to pass legislation that would boost federal funding for Medicaid and SCHIP.
Within the first few months of his administration, Obama also plans to push for investment in health information technology as a way to modernize the healthcare system and spur the economy, says Judy Feder, PhD, a professor and former dean of Georgetown University’s Public Policy Institute and a two-time Democratic congressional candidate who campaigned on a healthcare platform almost identical to the president’s.
Obama says he would like to direct $10 billion a year over the next five years to help the nation’s hospitals and healthcare providers install electronic billing and medical record systems.
“Somebody’s got to help set those up. We’ve got to buy computer systems and so forth. That’s an immediate boost to the economy…but it’s also laying the groundwork for reducing our healthcare costs over the long term,” Obama said in November upon naming Peter Orszag, an economist who regards rising healthcare spending as the nation’s top fiscal threat, director of the Office of Management and Budget.
Hospitals and hospitalists can benefit from IT advancements, but the technology should be slowly phased in to give users time to adjust, which may run counter to the quick economic stimulus Obama is trying to achieve, says David Meltzer, M.D., Ph.D., a professor in the department of medicine at the University of Chicago who has conducted considerable research in hospital medicine.
“The point is, health IT takes years to implement,” Dr. Meltzer says. “Just giving grants to buy and set up the equipment isn’t enough. You also want to give grants to prepare people on how to use it effectively.”
Dr. Meltzer is encouraged by Obama’s plan to create an independent, government-funded board charged with scientifically comparing the effectiveness of pharmaceutical drugs, medical devices, and procedures, and presenting the results to the medical community. He foresees hospitalists gaining opportunities to participate in clinical research as well as enroll patients in clinical trials.
“Over the long run, we’ll probably end up with therapies that will be better for patients and will control costs,” Dr. Meltzer says. “We spend a lot of money on things that don’t work or don’t work very well.”
Calling a comparative-effectiveness board “absolutely essential,” the Common-wealth Fund’s Davis says the U.S. has fallen far behind other countries in reviewing and rating therapies. Part of the reason is a fear that comparative effectiveness would stymie innovation and prevent doctors and patients from pursuing their choice of treatments, Dr. Meltzer says.
Opponents point to the book “Critical: What We Can Do About the Healthcare Crisis,” which Daschle and Lambrew co-wrote last year. In the book, Daschle advocates creating a federal health board outside the influence of Congress that would decide which procedures and therapies should be covered under public and private insurance plans. Obama has yet to support such a concept.
“There is that danger, but we live in an even more dangerous health system now,” says Dr. Meltzer, who predicts comparative-effectiveness legislation will advance this year. “I will be shocked and profoundly disappointed if we don’t see the legislation.”
Dr. Meltzer and other experts are less certain as to when Obama will move on other parts of his proposal, although Feder believes the president will try to create a national health-plan option and establish a national health insurance exchange, a kind of one-stop shop offering consumers health plans that would meet a minimum level of benefits, sometime in the next four years.
The national health-plan benefits could be similar to what federal employees receive, namely guaranteed health coverage and long-term care benefits, a wide variety of health plans to choose from, and insurability for pre-existing conditions. Private insurers would have to sell policies to everyone, regardless of pre-existing health conditions, and consumers who are unable to afford the premiums would be eligible for tax credits. The president’s plan stops short of requiring all Americans to have health insurance.
With more Americans insured, hospitals’ revenues will increase, according to Davis. Hospital patient loads—and hospitalists’ workloads—would increase, says Iris Mangulabnan, MD, a hospitalist at Covenant HealthCare in Saginaw, Mich.
“In the global scheme of things, if (Obama) is going to have insurance for about 45 million more patients, you’re going to see hospitals crammed with more people,” Dr. Mangulabnan says.
Adam Singer, MD, CEO of IPC: The Hospitalist Company, a national physician group practice based in California, says Obama’s plan has the potential to “overwhelm” the U.S. healthcare system. “Who’s going to take care of all these people?” he says.
Obama’s healthcare plan highlights preventive-care and disease management programs as ways to keep people out of hospitals and save money, but Dr. Mangulabnan says research has shown such initiatives aren’t always effective. “They hold a lot of conceptual promise, but I’m reminded of that fast-food commercial—you know, ‘Where’s the beef?’ ” Dr. Singer says.
Both doctors question how Obama’s healthcare plan, which would cost an estimated $75 billion a year when fully implemented, would be paid for. During his campaign, Obama talked about letting tax cuts expire for people making more than $250,000 a year and using that money for healthcare. But the economic crisis has forced the president to reconsider ending the tax cuts.
Cost is just one obstacle to Obama’s plan. Experts say the list also includes health insurers, pharmaceutical and medical product companies, doctors, congressional Republicans, an agenda full of other pressing problems, and change.
“It’s very difficult for a multitrillion-dollar industry to see the ground shift beneath it. It’s the known versus the unknown,” Davis says. “But I don’t see the economy as an obstacle. If anything, it increases the chance that healthcare will be addressed, because more people are being affected by problems in the system. The main thing that’s driving all of this is a feeling that it’s time.” TH
Lisa M. Ryan is a freelance writer based in New Jersey.