Health Care And The State Of The Union
January 26th, 2011
 by
Kavita Patel
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Below, Kavita Patel, former director of policy for the White House Office of Public Engagement and Intergovernmental Affairs, discusses President Obama’s State of the Union address and House Budget Committee chairman Paul Ryan’s (R-WI) Republican response. See other posts on this topic by Len Nichols and Joseph Antos.
The Constitution mandates that the President “from time to time shall give Congress information on the State of the Union and recommend to their consideration such measures as he shall judge necessary and expedient.” The speech is not only weighty in magnitude, symbolism and stature but is also surrounded by pomp and circumstance.
Last night’s speech by President Obama was no exception. Republicans and Democrats sat together, the airwaves were filled with speculation and anticipation and Speaker Boehner assumed his position of power next to Vice President Biden. A slight scandal even broke out early in the evening when a copy of the State of the Union speech was leaked in advance. The Economy and Jobs were the top issues, but health care and the President’s signature domestic accomplishment in the Affordable Care Act of 2010 received a fair share of attention before, during and after the speech.
Preventive Measures
Given the emphasis on deficit reduction, economic woes and the need for fiscal discipline, statements such as the one below from A. Barry Rand, the CEO of AARP, came as a strong warning even before President Obama took to the podium:
… any attempt to control spending in Medicare and Medicaid without addressing the causes of skyrocketing costs throughout the health care system will not reduce these costs, but rather shift them on to the backs of people of all ages and generations.
While efforts to reduce the deficit are important, we will continue to speak out against any plan offered by the administration or Congress that would target these critical safety nets for changes based on budgetary targets instead of their impact on the lives of everyday Americans.
Rand’s pre-emptive statement was similar to those expressed by other organizations and groups which have constituencies which would be seriously impacted by cuts to Medicare and other entitlement programs.
What the President Said About Health Care
The President spent a little under 300 words on health care, which at first blush might seem to be a small amount, but considering how precious the real estate is in the Address to the nation, it was an important acknowledgement that no matter how toxic the political atmosphere becomes the President will not abandon his commitment to high quality, affordable health care for all Americans. The President made clear that repeal was not acceptable but that improving the Act and finding some common ground would be acceptable. Proof of his willingness to change the Act came in the form of a promise to work to repeal the 1099 tax provision which requires businesses to file a 1099 form for expenses over $500. The topic of malpractice reform was also a clear olive branch to the other side of the aisle and the decision to include it in last night’s speech undoubtedly drew great debate internally by White House advisors, similar to the decision to discuss malpractice during the President’s 2009 speech to the House of Delegates of the American Medical Association in Chicago.
However accommodating the President may have been on certain issues, he made a strong statement about the positive aspects of the ACA. By pointedly emphasizing the ban on pre-existing conditions and the closure of the Medicare part D donut hole , Obama signaled the Administration’s confidence in the popularity of particular aspects of health reform that were non-negotiable and likely to draw great criticism if they are threatened by a GOP congress.
What the President Did Not Say
With regard to health care, there were a number of areas which did not make its way into the hour long address which merit emphasis and reinforcement. The regulatory process at the Departments of Health and Human Services, Labor, and Treasury is cranking away at breakneck speed and important guidance with implications for our nation’s health are currently being crafted, including:
- Language around creating accountable care organizations
- Value-Based Purchasing and Value-Based Insurance Design to promote high value health care
- Medicare Policies around hospital-acquired infections and readmissions
- Critical guidance around the design of health insurance exchanges for states
It is fairly obvious that it would not be wise to include all of these points in such a high level speech, but it would have definitely been worth noting that the Affordable Care Act is not a job killer; it is in fact an engine for the very innovation and discovery that was steeped in the President’s words last night. While only time will truly tell, policy experts and analysts know the following to be true:
- Health reform should slow the rate of growth of health care premiums, which in turn will help create confidence in expanding jobs and investing in human capital again.
- Investments in delivery-system innovations such as patient-centered medical homes, accountable care organizations and a serious realignment of the broken fee-for-service system of payment will create clear financial incentives to promote jobs in health care sectors that offer value and minimize harm and waste.
- Innovation in the biomedical sciences and building the pipeline from bench to bedside will be the only way our country can compete with the growing forces of China, Singapore, India, South Korea and the Middle East. Their investments in the biomedical sciences make our National Institutes of Health look trivial, and the pharmaceutical industry is already migrating to the East. Any decrease in these investments because of partisan divide will threaten our global competitiveness.
Another point that never had a chance to be included but is also worth reinforcing is the need for a more honest national dialogue around palliative care, death and dying. Recent studies have demonstrated the immediate and long term benefits of palliative care in a number of settings, including most recently Temel and colleagues in the treatment of lung cancer. Unfortunately a recent promulgation of a regulation to include payment for end of life counseling in Medicare was reversed for a host of reasons, but it did little to quiet the notion that the government is trying to institute “death panels.” A step in the right direction would be to promulgate the regulation and then ask the numerous non-profit organizations and philanthropic entities such as the Robert Wood Johnson Foundation, which invested millions of dollars in improving the conversation around palliative care, to help educate our country’s patients and providers. Real conversations are needed about helping clinicians talk to patients and families with compassion, humility and respect.
Finally, while the President mentioned a willingness to work on tort reform, there was little detail attached. Possibilities which have been previously proposed include caps, medical courts, and liability shields in cases where clinicians admit harm. But rather than try to delineate one specific proposal, the President should have added one simple sentence which would have mollified the GOP as well as speak to the multitudes of clinicians who are nervous that the Affordable Care Act will only intensify the sense that providers will have more perceived threats to their practice of medicine:
By working together on malpractice reform, I am sending a clear signal to patients and providers alike: I will work tirelessly to find solutions with anyone who is willing to protect the patient first and ensure that our finest clinicians will never feel like they are trapped in a corner between a dysfunctional legal system and doing what is right for all Americans.
The Republican Response
Rep. Paul Ryan (R-WI) delivered the coveted response to the State of the Union, a symbolic perch often given to rising stars in the party. This is certainly accurate for Ryan, who authored the “Roadmap to the Future” document detailing Medicare reforms and controlling costs in health care. Ryan was also brief in touching on health care, but he did emphasize a point that was NOT countered in the President’s address — that the Affordable Care Act will not control cost and will be a job killer in the US. As long as this point is not debated or refuted outright in a manner that is easy to understand for Americans, it will remain a topic of serious concern up until the 2012 Presidential elections.
Future Direction for the Health Care of the Country
Much like in real estate, it is location, location, location. Health care reform will look different in each community, and the call to leadership for health care in local settings has never been stronger. The Administration will face significant challenges, not the largest of which is the increasing scrutiny and oversight of spending. What this should trigger is less of a defensive posture and more of an opportunity to have a real dialogue with the country.
Furthermore, instead of relying on officials within the government who are already stretched beyond repair and operating on scarce resources (scarcer given the call for a freeze in spending), the Administration should activate and lean on the many clinicians who have been advocating for real health reform in their care settings every day. Conversations around stewardship of resources and how best to tackle rising costs by helping patients understand what works and what doesn’t in health care will be the real way to bend the cost curve, rather than economic modeling alone. By tapping into the effective surrogacy skills of these men and women who bravely demonstrate their calling to healthcare, Obama will not only reinforce the sentiments expressed last night but build on a social movement that has been swelling since the words of President John F. Kennedy.
Preview of the 2012 State of the Union
Health Care will likely receive the same proportion of time and words as it did this year, if not less. The 2012 speech will take place during a critical re-election year with many elected officials hoping that the Presidential race will drive voters to the polls. Health care may not be the central theme, but it is the job of policymakers, advocates, healthcare professionals and patients alike to make the case that 2011 was the year of innovation, discovery and job creation….in health care.
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