Politics Healthcare Reform and the Future of Neurosurgery – Tides of Change

James R. Bean, MD

In a presidential election year, longstanding policy conflicts float to the surface of the American political debate. It is a time of constitutionally planned instability in American governance, when policy principles are argued anew, ambitions flourish, rhetoric runs high, hopes soar, and aims are redefined. Candidates’ platforms expose the ideological gulfs that divide American political thought, and elections pose the chance for the world’s most successful democracy to devise anew its priorities and revise its direction for another four years.

Healthcare reform is again on the national agenda. Over the course of the past 75 years, healthcare reform reached a level of serious policy discourse in the administrations of Franklin Roosevelt, Truman, Johnson, Carter, and Clinton, each a Democrat. From the liberal perspective, healthcare reform embodies an unrealized quest for universal healthcare coverage, while from the conservative perspective it constitutes another run at socialized medicine. It invariably resurrects for public discussion the principles of individual entitlement and federal regulation versus individual choice and responsibility through market competition.

Healthcare Reform: A Recent History
Two legislative events in particular serve as examples of a political process that produces successful federal healthcare legislation in the post-1966 Medicare era. After the Clinton Health Security Act sank under the weight of intense political opposition in 1994, a more modest healthcare coverage goal was achieved in the 1997 bipartisan SCHIP legislation that expanded coverage to children who didn’t qualify for Medicaid. In 2003 the Senate Finance Committee crafted a bipartisan bill, the Medicare Modernization Act, which among others things expanded Medicare to include pharmacy benefits. Both bills involved compromise and aimed for limited, not radical, reform.

In 2007 a bipartisan compromise attempt to reauthorize SCHIP and expand the number of children eligible for the program passed by large majorities in both houses of Congress. President Bush vetoed the legislation, stating his opposition to “a step toward government-run healthcare for every American.” The veto turned SCHIP reauthorization into a referendum on federal healthcare reform.

Neurosurgery has an interest in this debate. Each piece of major federal healthcare legislation affects, directly or indirectly, the practice of neurosurgery. Public coverage and payment policy is mirrored in private healthcare policy, leaving no one immune to the decisions of federal lawmakers. Additionally, new political entitlements generally mean new federal program costs, commonly enacted without additional tax funding, which means renewed federal sallies to combat costs: fee cuts, bundled payments, coverage denials, and campaigns against fraud that turn billing errors into criminal abuse.

Political High Jinks of Summer

Tommy Thompson (left), a former secretary of the Department of Health and Human Services, and Tom Daschle, President-Elect Obama’s nominee for the post, frequently found themselves on common ground at the America’s Health Care at Risk conference in September.

An example of political high jinks occurred in June when Congress attempted to prevent the 10.6 percent Medicare physician fee cut that had been delayed since January. When bipartisan negotiations on a Senate Finance Committee compromise bill broke down over Medicare Advantage payment cuts, Democratic leaders brought bills that included the controversial Medicare Advantage provision to a vote in each chamber of Congress, inviting a presidential veto and creating political embarrassment for legislators opposed to the legislation as well as fodder for campaign leverage in an election year. The bill passed in the House 355 to 59, but failed a cloture vote (which prevents filibuster) in the Senate by a narrow margin. The 10.6 percent cut officially became effective July 1. The Senate returned from the Fourth of July holiday and reversed the cut, buoyed by the applause-stirring, surprise appearance of glioblastoma-plagued Ted Kennedy, with a 69 to 30 vote on July 9. President Bush vetoed the legislation on July 15, but both chambers swiftly overturned the veto by even larger margins: 383 to 41 in the House and 70 to 26 in the Senate. Physicians, spurred by the American Medical Association, celebrated victory as the fee cut was averted.

Three things can be learned from this summer’s vote. First, neurosurgery was not and should not be drawn into partisan wrangling. Healthcare legislation arouses strong partisan differences, bitter recriminations and deceptive political bargaining. The physician groups that supported the summer veto override won a Pyrrhic victory without achieving a permanent solution to the flawed sustainable growth rate formula that determines Medicare physician payments—fees remain flat for another 18 months, and 20 percent cuts in physician payments are looming in 2010—and they earned the resentment of the legislators they politically threatened without gaining any real concession from those they supported. This summer’s drama will be replayed until the sustainable growth rate formula is replaced by one that fits the reality of medical inflation. The next battle likely will occur in the setting of broader healthcare reform proposals, and Medicare physician payment and other key issues will be used as bargaining chips.

Second, neurosurgery must advocate for its defined principles and political goals without becoming a pawn, useful as a decoy but sacrificed for larger political purposes, for either side on a large political chessboard. We must define policy goals, stick to them, and stay out of the political mud fight. While legislative opponents brush themselves off and tackle the next fight, lobbying groups remain tarnished with the partisanship of the previous battle. A political opponent on today’s issue is an ally on tomorrow’s measure. Consistency with nonpartisan, principled positions prevents whipsawing between opposing parties and pays off in the long term.

Third, there is no final victory in advocacy. There is only an unending series of negotiations and a continuation of a political quest for compromise that satisfies the needs and budgets of diverse interests and opposing viewpoints today while preserving a process for negotiation and compromise again tomorrow.

Neurosurgery’s Stake in Anticipated 2009 Reforms
With the U.S. economy in recession, healthcare consuming 16 percent of the nation’s gross domestic product, and a new president taking office in January, we can expect healthcare reform proposals in 2009. They commonly are initiated as grand schemes to overhaul the U.S. healthcare system. Opponents whose interests are threatened by proposed changes use fear tactics and rhetorical exaggeration to publicly combat the measures. Successful proposals are generally those offered as compromise legislative agreements that do not overreach and that see U.S. healthcare reform, in the absence of true (not rhetorical) social crisis, as an incremental rather than revolutionary process.

The goals of neurosurgery are to preserve for all access to specialty care, to offer the best neurosurgical care available to those in need, to preserve professional judgment in healthcare, and to ensure fair compensation for services provided. We must stick to these goals and measure all reform proposals against them.

James R. Bean, MD, is the 2008-2009 AANS president. He is president and managing director of Neurosurgical Associates PSC in Lexington, Ky. The author reported no conflicts for disclosure.

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