Supporting (Opposing) Patient-Centered Outcomes

On July 17, the Republican-controlled House Appropriations Committee posted online the proposed, fiscal year 2013 spending bill for the Departments of Labor, Health and Human Services, Education and related agencies.

This bill would end health care research in the following areas:

• The bill ends all funding for the Agency for Healthcare Research and Quality (Sec. 227).
• The bill prohibits any appropriated funds from being used for patient-centered outcomes research (Sec. 217).
• The bill prohibits funds appropriated for the National Institutions of Health (Title II, page 57, lines 20-24) from being used for any economic research.

The second one is strange, because "patient-centered" is a phrase developed in focus groups by Republican pollster Frank Luntz to describe Republican health care policies. For some examples of Republican comments using the phrase following the Supreme Court's decision on the Affordable Care Act, see David Weigel's blog posting on Slate on July 2.

And I found these other more recent examples on Twitter:

• Americans for Prosperity: "RT if you reject the government takeover of #healthcare & want real, patient-centered reform!" (7/20/12)
• George Allen: "I want to be the deciding vote to repeal this health care law & replace it with patient-centered reforms for more affordable health care." (7/16/12)
• Sarah Palin (via Kim Moons): "Our vision is of an America where health care is affordable, it's patient centered, and it's market driven."

So Republicans are in favor of patient-centered care, but are not interested in spending money for any research into what would be effective patient-centered care?

Even more confusing is that patient-centered care is an important part of the Affordable Care Act that Republicans want to repeal.  The phrase "patient-centered" (or "patient-centeredness") appears 15 times in the ACA, not counting the headings of titles, sections, and subsections, and not counting references to the "Patient-Centered Outcomes Research Institute" or the "Patient-Centered Outcomes Research Trust Fund."

One of the main ways that the ACA is supposed to hold down Medicare costs is through "accountable care organizations" (ACOs) and one of the requirements of an ACO is that it meet patient-centeredness criteria to be established by the Secretary of Health & Human Services.  (Sec. 3022)  And one of the ways that the ACA is supposed to hold down Medicaid costs is through supporting the creation of "patient-centered medical homes."  (Sec. 3502)

But Republicans want to repeal the whole ACA, including its provisions for patient-centered care, in order to enact patient-centered care, and meanwhile are working to block any research into developing models or techniques for patient-centered care.

This is terribly schizophrenic.  There are either conflicts and disagreements within the Republican party, or the whole Republican "patient-centered" talking point is just a smoke screen for repealing the ACA without offering anything in its place.

My vote is the latter.

Why Health Care Reform Won't Be Repealed

Even if Republicans were to get majorities in both houses of Congress, there really is no likelihood of health care reform being repealed, because repeal won't have full Republican support, despite what Republican may be claiming in their "Pledge to America."

Republicans are claiming to support, and re-enact, all the things that people like. Specifically:

We will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition, eliminate annual and lifetime spending caps, and prevent insurers from dropping your coverage just because you get sick.

Of course, the Patient Protection and Affordable Care Act of 2010 already does all those things, and those are the parts of the act that people like and support. What the Republicans want to get rid of are what are referred to as the "burdensome mandates," such as the requirement that all but the smallest businesses provide health insurance for employees, and the "individual mandate" that requires individuals not covered by employer-provided insurance to get health insurance or pay a special tax.

The reason that Republicans won't be able to repeal those parts of the act is that those are the parts of the act that the insurance industry likes. Requiring insurers to provide insurance to sick people without requiring healthy people to buy insurance is a prescription for economic disaster, because there would be nothing to stop healthy people from dropping their coverage until after they get sick. So insurers would have to provide the same (or greater) levels of benefits while the number of insureds shrinks, which would cause premiums to skyrocket.

And Republicans know this, which is why the "Pledge" is so specific about the parts of the act that they would want to keep and so vague about exactly what would be repealed. They know that, if they come right out and say that they are going to repeal the employer and individual mandates, they will be (or at least should be) ridiculed for proposing a completely unworkable system.

So if the Republicans actually try to repeal health care reform with actual legislation, they will be caught between a rock and a hard place. If they repeal the entire health care reform act without providing patient protection they will anger voters, but if they repeal the employer and individual mandates and leave the patient protections in place they will anger (if not bankrupt) some of the biggest contributors.

So it's pretty safe to say that there's going to be lots of rhetoric, but not much actual repeal.