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The doctors vs. the Republicans

Well, the "doc fix" failed. Rather than reworking the Medicare payment formula that Congress doesn't follow, Congress will keep the formula on the books (and on the deficit projections) and simply ignore it on a year-by-year basis.

Democrats got off easy on this one. If you ever wondered why they were pursuing a $237-billion deficit-buster in the middle of health-care reform, the answer was that this was the highest priority for the doctor's groups, and Democrats wanted the doctors group's support on health-care reform more broadly. Getting it, however, opened them to charges of blowing up the deficit, or hiding the full cost of health-care reform.

But now the bill is dead and Democrats didn't kill it. Republicans did. Jon Kyl, who had cosponsored the original legislation, abandoned it. The 27 Republican senators who'd been expected to support the bill walked away as soon as it seemed like a good issue to use against the Democrats. That, in turn, scared moderate Democrats, and the bill died -- at least for now.

This is arguably the best possible outcome for the Democrats: They don't have to pass a bill that increases the deficit, but they get with the docs credit for trying, and the American Medical Association is furious at the Republicans. The losers here seem to be doctors, who still will be facing the uncertainty of payment reforms every year or two, and budget hawks, who still will be watching Washington operate off budget projections that have a big lie in them.

By Ezra Klein  |  October 22, 2009; 9:20 AM ET
Categories:  Health Reform  
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I'd be more than happy to pay for the doc fix using the savings from the Medicare+5% Public Option.

Apart from that I don't see how this is the best outcome for Democrats. Reid looks like he can't count. Conservadems have set a precedent for voting against their party on cloture. The AMA says it will not accept a one year fix. None of these is a good thing.

Posted by: bmull | October 22, 2009 9:43 AM | Report abuse

Thanks, Ezra. You explained in four short paragraphs the sum of the political and fiscal impact of the swing-and-a-miss at an SGR fix. And you're right. Nobody really much holds Babe Ruth's strikeouts against him, either.

Posted by: Rick00 | October 22, 2009 9:45 AM | Report abuse

well maybe THEY SHOULD follow it or find a way to. You said yourself many times Ezra that the fee for service model doesn't work. WE ALL AGREE THAT THAT'S WHAT DRIVES COSTS. Why not switch to capitation that has worked in the past in the US. That could take the place of the doc fix and it wouldn't be a short term gimmick, it would be a permanent fix. Republicans are being blamed here by you for not continuing something you said was a bad idea in the first place. I think we all know their reasoning for doing it but in the end if the result is costs are more in line and everyone ends up with access then how is that a bad thing? You need to change the fundamental structure of how doctors get paid to reform the system and going to capitation (no matter who much people hated it before) is the only system that has been shown to do that.

People push the idea of Canadian style healthcare as more "universal" and "economical". Well they have capitation there. They tell docs what they make. You can't have your cake and eat it too. You can't have the freedoms of fee for service and the access for all of universality. Sorry at some point the rich won't let you tax them THAT MUCH.

Its one of the other, take your pick.

Posted by: visionbrkr | October 22, 2009 9:54 AM | Report abuse

Ezra - i disagree. This doesn't seem like the best possible outcome for the Dems to me. The best possible outcome was passing the fix. Then the AMA and docs get what they want and push harder for reform bills.

12 Dems voted against this bill. They helped kill it. And now Dems want AMA and doc support for a reform bill? A bill that will cut Docs payments by 25% in 2011. Why should the AMA and Docs trust Dems' ability to deliver now? Reid says he'll revisit doc fix after reform -- why should this be acceptable to docs?

This was an issue that Dems all support and some Repubs support but it couldn't get passed. This tells me it could be harder to pass reform than i thought. Dems caved and Repubs held the line. Reid got played and now the AMA is upset. None of these things increase the llikelihood that reform will get passed.

Posted by: mbp3 | October 22, 2009 10:00 AM | Report abuse

Republicans have no power whatsoever in Washington!!! How can you even argue that the Republicans killed it when they have zero, I repeat, ZERO political power at the federal level of government?

Posted by: lancediverson | October 22, 2009 10:02 AM | Report abuse

"Democrats didn't kill it. Republicans did."

Republicans have gained control of Congress?! Without an election!? There's nothing on the news about this, and you'd think that it would be front page news! Please elaborate!

Posted by: ostap666 | October 22, 2009 10:06 AM | Report abuse

It's even better than you say. Since the doc fix wasn't just budgetary honesty but also also payment to the AMA for support for reform, the Republicans flip flop means that the Democrats can get more from the AMA in the future.

The need for a yearly delay in th medicare cuts means that there will be one bill a year which the AMA must accept. Or else there can be a new big deal with a major reform in exchange for a permanent end to the charade. Since, no matter what happens this year, there will be plenty of reforming to do, and much of it will reduce the huge incomes of MDs, this is an excellent result.

The AMA knows what just happened to AHIP. They understand, they are powerful, but blatantly changing their stated analysis of health care reform, because they didn't get the dox fix will hurt them. Actually, the example of what happened to the GOP already demonstrated that, believe it or not, it is possible to hurt yourself by being too cynical and dishonest for Washington DC.

Knowing how to play 11 dimensional chess is good. Being lucky is better. Having the Republicans for opponents is best.

Posted by: rjw88 | October 22, 2009 10:16 AM | Report abuse

So, 1 Republican voting with Democrats on a committee vote = bipartisan coopperation while 12 Democrates voting with Republicans on a floor vote = partisan obstruction?

Posted by: WoodbridgeVa1 | October 22, 2009 10:25 AM | Report abuse

From the cited report, "The vote failed cloture 47-53" regarding a bill "the AMA, AARP and MOAA strongly supported".

Again, recall that there are 60 members of the Senate Democratic Caucus.

Posted by: rmgregory | October 22, 2009 10:27 AM | Report abuse

I notice that, in my comment above, I am assuming that the Democrats will keep their majority for a good while. Republican behavior might almost make some sort of sense under the assumption that they will win back the Senate some time soon.

They are telling the AMA that compromise with Democrats will be punished. They assume this will lead to more fear than anger, because they are a very scary soon to be majority party.

Further if they are in the majority, the annual doctor fix will increase their power, because, with the majority, they will decide what riders to put on the must pass bill.

So they are totally dishonest, and living in a dream world. However, the Republicans can at least imagine that they have a strategy.

Posted by: rjw88 | October 22, 2009 11:00 AM | Report abuse

When retaining a legal epicycle that obscures budgetary realities is the best outcome for either party, something is very wrong with our legislative system. Am I wrong?

Posted by: janinsanfran | October 22, 2009 11:12 AM | Report abuse

Here is the thing. Some doctors are paid too much and some are not paid enough, and a solution has to be found to the problem of profiting from referrals to imaging services, etc.

I don't know why nothing has been done about this, but my interim fix would be: identify PCP services and vote them an increase, and then keep most specialty services constant (no cut, no increase). I am sure MedPAC will tell us it's more complicated then, fine, solve it.

But this is really and truly a serious problem.

Posted by: rb63 | October 22, 2009 6:12 PM | Report abuse

The real loser is "truth" and "honesty".

And the politicians wonder why everyone hates them and nobody trusts them ... this is why.

Posted by: cautious | October 23, 2009 2:52 AM | Report abuse


I'll take that one step further. Why not tell providers that either:

1)they cannot own a stake in a radiology center that they refer patients to


2)make providers disclose to patients that they own a stake in said radiology center

I'd prefer #1 realizing i'd probably not get it.

Posted by: visionbrkr | October 23, 2009 10:04 AM | Report abuse

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