Budget, Tax Issues Could Delay National Health Care Reform

The next presidential administration and Congress likely will have little money or time for major health care reform efforts during the next few years because they will be engaged in a prolonged debate about budget and taxes, according to analysts interviewed recently by AAFP News Now.

"I don't believe national health care reform is going to occur terribly soon," said FP Richard Wender, M.D., alumni professor and chair of the department of family and community medicine at Thomas Jefferson University Hospital in Philadelphia. "It would demand a president willing to put his or her reputation on the line, a congressional majority of the same party, broad public demand and confidence that it can be done."

The next president and Congress will have to address pressing budgetary concerns in 2009 and beyond, including the federal deficit, the national debt and the expiration of the Bush administration's tax cuts in 2010 -- urgent issues that will shift attention and resources away from national health care reform efforts, according to Wender and other analysts. As a result, the federal government is more likely to implement incremental changes instead of major health care reforms for the foreseeable future, making it possible that states will be forced to enact sweeping health care reform initiatives that will serve as "vehicles for experimentation and learning," said Wender.

For the most part, states are approaching health care reform in two ways. Some states have sought to reform health care systems by expanding insurance coverage. Other states have incorporated quality incentives, paid more money for primary care services and adopted care coordination. Solutions vary on a state-by-state basis, which provides the federal government an ideal opportunity to find out what works and what doesn't and to adopt successful strategies as part of a national health care reform plan.

"Once 15 or 20 states have made meaningful change, it will not look so daunting to come up with a national plan," said Wender.

The United States is not "in a position where we can just have an across-the-nation, public health-driven solution," said Wender. We are going to need a uniquely American solution to our uniquely American method of health care," requiring new collaborations and "some strange bedfellows," he predicted.

For example, said Wender, national health care reform will not succeed without input from the insurance industry and large employers, a point reiterated by Helen Darling, president of the National Business Group on Health, which represents large employers.

"First of all, (large employers) want health care reform," Darling said. "(They) think we have a totally dysfunctional health care system."

Darling, like Wender, said any meaningful health care reform on the national level will require a restructuring of the nation's payment system to recognize and reward primary care and the patient-centered medical home. For example, health care payers should reward physicians for coordinating care and serving as patient-centered medical homes, which would include paying them for services such as phone and e-mail consultations and group visits, said Darling.

She added that one of the most effective ways of changing the payment system is to restructure Medicare so that it places a greater emphasis on preventive and primary care services, because most of the nation's public and private payment systems are patterned after Medicare.

Darling and Wender said they are optimistic about the prospects of primary care under a national health care reform plan. Any successful national health care plan, they noted, will have to address cost considerations, making primary care and the patient-centered medical home key components of any major plan since both, if designed and executed correctly, will result in cost savings and improved quality.

"Increasingly, forces around the nation, including the insurance industry and the for-profit aspects of health care delivery, will want to change incentives to promote a greater emphasis on primary care," said Wender.