Public Option Not Single-Payer, Obama Says

    President Obama told American Medical Association delegates on June 15 that the Health Insurance Exchange Program, or public option, portion of his health system reform plan is not "a Trojan horse for a single-payer system."

    "I'll be honest," he said in a speech to the annual AMA meeting in Chicago. "There are countries where a single-payer system may be working. But I believe – and I've even taken some flak from members of my own party for this belief – that it is important for us to build on our traditions here in the United States. So, when you hear the naysayers claim that I'm trying to bring about government-run health care, know this – they are not telling the truth."

    The president said the exchange program would allow patients "to one-stop shop for a health care plan, compare benefits and prices, and choose a plan" that's best for their families. They could choose from a number of plans that offer a few different packages, "but every plan would offer an affordable, basic package. And one of these options needs to be a public option that will give people a broader range of choices and inject competition into the health care market ... and keep the insurance companies honest."

    Mr. Obama said he knows physicians "are concerned that today's Medicare rates will be applied broadly in a way that means our cost savings are coming off your backs. These are legitimate concerns, but ones, I believe, that can be overcome."

    He said the reforms he proposes "are to reward best practices, focus on patient care, not the current piece-work reimbursement. What we seek is more stability and a health care system on a sound financial footing. And these reforms need to take place regardless of what happens with a public option. With reform, we will ensure that you are being reimbursed in a thoughtful way tied to patient outcomes instead of relying on yearly negotiations about the Sustainable Growth Rate formula that's based on politics and the state of the federal budget in any given year. The alternative is a world where health care costs grow at an unsustainable rate, threatening your reimbursements and the stability of our health care system."

    The president said he wants to change the focus of health care from the quantity of treatment to the quality of care. Physicians should be able to concentrate on treating patients instead of worrying about a system that bases pay on the amount of tests and services, he said. 

    The president called rising health care costs a threat to the economy, a burden on families and businesses, and a "ticking time-bomb" for the federal budget. Unless costs drop, he warned, "America may go the way of GM – paying more, getting less, and going broke." 

    America now spends more than $2 trillion a year on health care, yet "more of our citizens are uninsured; the quality of our care is often lower; and we aren't any healthier. In fact, citizens in some countries that spend less than we do are actually living longer than we do."

    He blamed the bulk of health care costs not on an aging population needing more care, but on "the nature of our health care system itself – a system where we spend vast amounts of money on things that aren't making our people any healthier; a system that automatically equates more expensive care with better care."

    He cited an article in the June 15 New Yorker that said that McAllen spends twice as much as El Paso County on health care, "not because people in McAllen are sicker and not because they are getting better care. They are simply using more treatments – treatments they don't really need; treatments that, in some cases, can actually do people harm by raising the risk of infection or medical error. And the problem is, this pattern is repeating itself across America."

    Mr. Obama faulted "a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I'm talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can't spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it's not truly necessary. It is a model that has taken the pursuit of medicine from a profession – a calling – to a business.

    "That is not why you became doctors. That is not why you put in all those hours in the anatomy suite or the OR. That is not what brings you back to a patient's bedside to check in or makes you call a loved one to say it'll be fine. You did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers – and that's what our health care system should let you be."

    President Obama called for reforming the way physicians and hospitals are compensated. "We need to bundle payments so you aren't paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease. We need to create incentives for physicians to team up – because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes – so that we are not promoting just more treatment, but better care."

    He said reform "is not a luxury, but a necessity. I know there has been much discussion about what reform would cost, and rightly so. This is a test of whether we – Democrats and Republicans alike – are serious about holding the line on new spending and restoring fiscal discipline. But let there be no doubt – the cost of inaction is greater. If we fail to act, premiums will climb higher, benefits will erode further, and the rolls of uninsured will swell to include millions more Americans.

    "If we fail to act, one out of every five dollars we earn will be spent on health care within a decade. In 30 years, it will be about one out of every three – a trend that will mean lost jobs, lower take-home pay, shuttered businesses, and a lower standard of living for all Americans.

    "And if we fail to act, federal spending on Medicaid and Medicare will grow over the coming decades by an amount almost equal to the amount our government currently spends on our nation's defense. In fact, it will eventually grow larger than what our government spends on anything else today. It's a scenario that will swamp our federal and state budgets, and impose a vicious choice of either unprecedented tax hikes, overwhelming deficits, or drastic cuts in our federal and state budgets.

    "To say it as plainly as I can, health care reform is the single most important thing we can do for America's long-term fiscal health. That is a fact."

    President Obama concluded his speech by saying he does not want "our children and their children to still be speaking of a crisis in American medicine 50 years from now. I do not want them to still be suffering from spiraling costs we did not stem or sicknesses we did not cure. I do not want them to be burdened with massive deficits we did not curb or a worsening economy we did not rebuild."

    Texas Medical Association President William H. Fleming III, MD, called the speech "well-prepared and well-delivered," but said some of it troubled him.

    He cited President Obama's declaration that he does not support caps on liability lawsuit awards. "Caps are what made liability reform work in Texas," Dr. Fleming said.

    However, Dr. Fleming said he believes there is room for compromise as the debate over reform continues.

    Then-AMA President Nancy H. Nielsen, MD, said that like the president, "the AMA is committed to health reform this year that provides all Americans with affordable, high-quality health coverage. We have a historic opportunity for reform this year, and the AMA is actively working for health reform that covers the uninsured, makes insurance more affordable, increases the value our nation receives from its health-care spending, and enhances prevention and wellness for patients."

    Action, June 16, 2009


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