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What to do about the doc fix?

There were many moments during the health-care reform process where the participants did not exactly cover themselves in glory, but the one that is going to cause the most ongoing annoyance was the punt on the rates that Medicare pays doctors.

You're all probably as tired of reading this as I am of explaining it, but here, again, is the quick background. In 1997, the Republican Congress created a payment formula meant to govern Medicare called the Sustainable Growth Rate. The formula was supposed to be a little tweak that saved a couple billion dollars. But the formula was wrong, and it quickly proved a wrenching readjustment that would've driven physicians out of the program by sharply slashing their payments. But rather than undo it, Republicans in Congress, and then Democrats when they took over Congress, passed temporary fixes, because no one wanted to come up with the money to fix the thing permanently.

When health-care reform started, Democrats made an admirable effort to end the shell game and just fix the system. But doing so cost almost $300 billion, and Republicans, who caused this mess in the first place, attacked the Democrats' fix as if it was part of their health-care reform plan rather than part of the Balanced Budget Act that Republicans passed in 1997. So Democrats abandoned the effort and left the fix out of health-care reform.

But the SGR isn't something you can just ignore. If you do, it'll slash doctor payments by more than 20 percent, driving them out of Medicare. As with raising the debt ceiling, SGR is one of the unpleasant tasks for whoever happens to be in the majority at any given moment. But in an impressive bit of alchemy, Republicans used health-care reform to pin the doc fix on Democrats and are now much more able to unite their party against protecting seniors from SGR, which has in turn forced Democrats to pass shorter and shorter fixes.

At some point, this has to end and we just have to fix the thing. A permanent fix will cost $300 billion (though that's an imaginary cost, as we were never going to see that $300 billion), and the doctors want it bad enough that you could presumably make some big gains on payment reform as the price for getting it done. It would be nice if the wise men (and women) from both parties were hammering out some private compromise for after the election. All those Republicans who felt that the Affordable Care Act didn't do enough to move toward pay-for-performance could use this as their opportunity. But if the two sides think it's more useful as a cudgel than a bargaining chip, it's hard to imagine anything good coming out of the process.

By Ezra Klein  |  June 21, 2010; 10:59 AM ET
Categories:  Health Reform  
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Comments

--"So Democrats abandoned the effort and left the fix out of health-care reform."--

Which also had the dishonest effect of keeping the low-ball cost of reform below a trillion dollars.

And the crisis deepens...

Playing with other people's money is just one nightmare after another, ain't it, Klein?

Posted by: msoja | June 21, 2010 11:35 AM | Report abuse

So, when passing the PPACA, those who voted for it knew with certainty the cost of the program would ultimately be at least $300 billion higher than estimated, eliminating every last dime of the purported $124 billion in "deficit reduction."

[Sarcastically] I wonder why those [Democrats] voting for the PPACA didn't simply include the DocFix into the PPACA or its amendment? Could it be that honest numbers might have scared the socks off of the taxpaying public?

Posted by: rmgregory | June 21, 2010 11:50 AM | Report abuse

"Playing with other people's money is just one nightmare after another, ain't it, Klein?"

I'm curious. Do you ever get bored playing with yourself all the time?

Posted by: slag | June 21, 2010 11:52 AM | Report abuse

"If you do, it'll slash doctor payments by more than 20 percent, driving them out of Medicare"

That's a feature, not a bug.

Posted by: NoVAHockey | June 21, 2010 12:20 PM | Report abuse

Claiming that not adding the doc fix to ACA is dishonest accounting is as reasonable as claiming not adding the cost of the war in Iraq to ACA is dishonest accounting, aka, not reasonable at all.

Posted by: jldarden | June 21, 2010 12:29 PM | Report abuse

I wonder if we can make this talking point about the doc fix being part of ACA as absurd as possible. I'd start by saying the doc fix should be attached to any one of the thousands of legislative actions over the past 13 years and should also include the all other provisions of law we don't intend to take effect (e.g. we don't expect the tax cuts for the middle class will expire, we are never going to extend the AMT to the "middle class").

I'd hope we can get the talking point that renaming a Texas post office really cost $1 trillion, but the Democrats hid the cost.

Posted by: windshouter | June 21, 2010 1:03 PM | Report abuse

Well let's just fund more WARS to make sure those evil doctors don't get paid enough to take care of us.
Where is that debate?
Why don't people realize that it's WAR and so-called 'defense' dept. boondoggles that are robbing us boomers of our future health?
(Defense Dept. budget $1 trillion/yr.; Iraq and Afghanistan over $1 trillion each so far.)

Posted by: bobgil | June 21, 2010 1:14 PM | Report abuse

--"Why don't people realize that it's WAR and so-called 'defense' dept. boondoggles that are robbing us boomers of our future health?"--

Why don't people realize that "WAR" boondoggles are the other side of the same coin that includes "HEALTH" boondoggles.

Ending defense waste and incompetence won't make Medicare/Medicaid/Socialist health care any more actuarially sound. It will just provide a temporarily larger pool from which to steal.

Posted by: msoja | June 21, 2010 1:21 PM | Report abuse

Conservatives cheered their legislators on as they beat up Dems for including a $300 doc fix.

The Dems get tired of that particular beating and take the doc fix out.

Conservatives criticize Dems for taking out the Doc fix and making the bill cheaper.

Does not compute.

Posted by: MosBen | June 21, 2010 1:32 PM | Report abuse

--"I'm curious."--

I bet you are.

Klein is as far in over his head as Obama is his.

Posted by: msoja | June 21, 2010 1:34 PM | Report abuse

It's comical when political parties blame the other for the countries problems, yet always so short on information and facts to back their claims.

Ezra:

"Republicans, who caused this mess in the first place"

No facts, no info, just opinion.

Party Loyalists, regardless of what party, are the root of all the countries problems. These loyalists are blind sheep and will vote the party line regardless if it's good for the country or not. Benefits to the party take precedence over benefits to the country.

It's really pathetic and actually sad that these party loyalists can't think for themselves. I vote based on programs and policies that I agree with and that I believe will be good for this country. I don't care what party they belong too. Too bad others don't vote the same way. Instead they need to be told how to vote.

Very very sad example of 'American'. Founding Fathers would be disgusted with you. Given the socialistic agenda of current administration, the Founding Fathers probable wonder why they even fought the revolution.

Posted by: cglupker | June 21, 2010 2:17 PM | Report abuse

Except, of course, that what Ezra said isn't a matter of opinion. It's a fact that the Republican-controlled Congress passed SGR in 1997.

Posted by: jldarden | June 21, 2010 2:41 PM | Report abuse

Yes but to say SGR is the reason for health care problems is ridiculous. And also to say one bill creates all the problems is just as ridiculous.

Obama just gave a speech about accepting responsibility, not blaming others, yada yada yada. Yet that is all politicians and party loyalists do: blame others. Ever since that Obama speech, he's been documented a number of times blaming others. It is crystal clear that Obama is in well over his head and not up to the job. Bush wasn't so much in over his head, but he did have corporate loyalty issues (big oil).

I didn't really care for Bush and was dissapointed at the lack of competition he had in his second term elections. Then this election we get dumb (McCain) and Dumber (Obama). 300+ million people in this country and these were the two best we could find? No wonder other countries laugh at us now. McCain concedes the election by picking Palin. Our government leaders have 'gone dumb'.

Our government is filled with 2-year olds that spend more time fighting with each other than being productive. Party loyalists fall into that just as much.

Washington is a train-wreck and people need to grow up and start acting like adults. Blaming others and finger pointing is something little kids do. A TRUE leader accepts the problems and focuses on solutions. Maybe one day we will have a true leader run our country. The current administration is a joke and Bush was a puppet to big oil.

Posted by: cglupker | June 21, 2010 3:55 PM | Report abuse

How silly to try and pin all the blame on the Republicans when both parties have been and continue to be craven cowards for not having the guts to fix the problems and for the dishonest accounting in which they engage on a daily basis. The American public is becoming more alert to the shenanigans of those who are supposed to represent their interests and they're giving closer scrutiny to the continual money shuffling Congress engages in to promote whatever's on their agenda at any given time. Right now, the Democrats are in the headlights as they try to conceal the true costs of their very pricey wish list.

Posted by: Lilycat1 | June 21, 2010 3:58 PM | Report abuse

jldarden "Except, of course, that what Ezra said isn't a matter of opinion. It's a fact that the Republican-controlled Congress passed SGR in 1997."

I believe that the President that did not veto the item was named Clinton.

Posted by: tomhamand | June 21, 2010 4:20 PM | Report abuse

Cglupker, your arguments would be stronger if you learned how to read. Ezra never said that SGR is the reason (or even a reason) for health care problems. He said it was dishonest (and it is dishonest) to claim the cost of the patch was part of the health care bill.

Posted by: jldarden | June 21, 2010 4:26 PM | Report abuse

And Lily's arguments would be stronger if they were so obviously false. You chastise the Democrats for being "craven cowards", even though they made an actual attempt to address the problem. They also eliminate many of the Bush era budget gimmicks (such as pretending the wars didn't have a cost).

Posted by: jldarden | June 21, 2010 4:29 PM | Report abuse

This is yet another example of the good, the bad, & the political.

A) Congress, read as the Democratic majority, knew full well that the Dox Fix was key to getting insurance reform (It isn't healthcare) passed.

B) The CBO stated that paying for the PPACA would not yield the financial result promised by Reid, Pelosi & Obama if the Doc Fix was passed. Yet, the Congress forged ahead as if nothing was wrong. We, the people, were duped.

C) The SGR is, indeed, a train wreck. Unfortunately, we live in America, the land where our legislators (both parties) are unwilling to be wrong in the face of overwhelming evidence to the contrary and make stopgap after stopgap fixes to something that should be addressed once and for all. The Congressional leaders in both Houses and both parties should be taken to the woodshed.

"Ancient Rome declined because it had a Senate, now what's going to happen to us with both a House and a Senate?" ~ Will Rogers

Posted by: riskexcellence | June 21, 2010 4:31 PM | Report abuse

Let me see if I have this straight Mr. Klein. The Republicans, in an attempt to slow the growth of Medicare passed legislation that it turned out was too severe a remedy. Correct?

Instead of repairing the error in subsequent legislation both the Republican and Democrat controlled Congresses only passed temporary patches to the system while leaving the original legislation in tact. Correct?

In passing their widely disliked Health Care Reform pkg. the Democrats tried to hide the $300 billion dollar price tag for 'fixing' this problem even after it was pointed out to them as a legitimate expense if they were really serious about a meaningful reform. Correct?

So now this is a problem that is actually the Republicans fault and not the Democrats, who instead of fixing the problem have just continued their earlier practice while denying that they are in fact doing so !!

This is the classic type of partisan political spin that has gotten both parties and our government in to such a bind with the voters. You guys simply can't be bothered to tell the truth anymore. You compulsively cover-up, spin, obfuscate, and down right lie to the point where this $300 Billion dollar cover-up becomes only an annoyance instead of the health care deal killer it should have been.

You have some big ones Mr. Klein.

Posted by: Sproing | June 21, 2010 4:53 PM | Report abuse

"....Republicans, who caused this mess in the first place, attacked the Democrats' fix as if it was part of their health-care reform...."
_________________________________________________________________
Mr. Klein, you've used some loaded language in this example and others. Your bias is unattractive and lacks journalistic integrity. Are you saying that the Republicans prevented the Democrats from the creating the HCR that they wanted? The one that will bankrupt our children? The one that provides for an additional 30 million people, a majority of whom will be illegals or newly amnesty recipients.
As I recall, the Dems were in complete control of HCR. And, Dems did not hesitate to pass the fiasco that the majority of voting Americans were against. The meetings were closed, blah, blah, blah; we know the "crimes" committed during that scam.

The Dems have been able to do whatever they have wanted to do. Republicans warned them that they could not remove more money from Medicare and that seniors would suffer. No argument there, right? Dems insisted on spending our money -- no incremental improvements in the system....just payoffs and spend, spend, spend.
This president is a joke on the American voters - and you, Klein, are a buffoon.

Posted by: pjcafe | June 21, 2010 6:18 PM | Report abuse

On Health Care Reform, Ezra has proven himself to be seldom informed but never in doubt. If only I had some swamp land to sell this clown. Instead, he is selling smoke as part of Obama's hopey changey agenda. Just why is it the Republicans are convinced the tooth fairy never lived? He's already in the White House.

Posted by: buggerianpaisley1 | June 21, 2010 8:07 PM | Report abuse

The real cost from the doc fix probably comes from the inability for doctors to plan their practices around constant uncertainty in their medicare payment rates. Not in the imaginary budgetary hit.

Responding to the other commenters on this post: the absence of the doc fix in hcr is certainly the fault of Republicans. They chose to politicize and manipulate some of the best reforms in hcr; including the doc fix. They had the option to work on fixing a serious problem and chose not to. To this day, one of the biggest conservative talking points against hcr is that it wasn't really deficit neutral because of the doc fix; pretty much stupidity cubed.

There were only a few Republican Senators that even pretended they were interested in fixing this Nation's healthcare problems.

Posted by: zosima | June 22, 2010 1:52 AM | Report abuse

No, jldarden, the Democrats didn't try to fix the problems. They tried to toss favors to their friends and supporters, and in so doing they've managed to exacerbate the problems. You'll notice that I blamed both parties; sorry that your partisan mind missed that point. Both parties have and still do engage in dishonest accounting. I haven't any faith in either of them. Our government is out of control and ineffective and it is that way because we've turned a blind eye to the machinations of those who run it.

Posted by: Lilycat1 | June 22, 2010 8:44 AM | Report abuse

Wise men (and women)??? Why am I in parentheses?

Posted by: ashand49 | June 23, 2010 8:41 PM | Report abuse

Wise men (and women)??? Why am I in parentheses?

Posted by: ashand49 | June 23, 2010 8:47 PM | Report abuse

Isn't it funny how he uses the "Republican Congress" when talking about 1997, even though Bill Clinton signed it into law. On the other side, they use Bush as the punching bag, when the Democratic Congress had budget deficits every year since they took control in 2007, the lowest budget deficit was higher than any Republican deficit before then.
When we hear stories about "No Child Left Behind", it's always attirbuted to Bush. However, the media conveniently leaves out the fact that this bill was co-sponsored by Teddy Kennedy and George Miller, both Democrats.
Don't get me wrong, it takes a President signature to enact it into law, but the wording exposes the media bias that we complain about today.

Posted by: slake2 | June 24, 2010 4:58 PM | Report abuse

Isn't it funny how he uses the "Republican Congress" when talking about 1997, even though Bill Clinton signed it into law. On the other side, they use Bush as the punching bag, when the Democratic Congress had budget deficits every year since they took control in 2007, the lowest budget deficit was higher than any Republican deficit before then.
When we hear stories about "No Child Left Behind", it's always attirbuted to Bush. However, the media conveniently leaves out the fact that this bill was co-sponsored by Teddy Kennedy and George Miller, both Democrats.
When the MSM talk about the fiscal responsibility of Clinton, who balanced the budget in the late 1990s, do you think they give credit to the "Republican Congress"?
Don't get me wrong, it takes a President signature to enact it into law, but the wording exposes the media bias that we complain about today.

Posted by: slake2 | June 24, 2010 5:01 PM | Report abuse

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