By Tom Banning
TAFP Chief Executive Officer/Executive Vice President
At the risk of sounding overly cynical, epiphanies in politics are rare, if they exist at all. Ground-breaking legislative reforms are more likely to evolve from several years of toiling in the political trenches. Even then, legislative breakthroughs may be a result of sheer unanticipated luck, stumbling by an opponent, an inadvertent absence of a determined adversary, or the weird and largely unplanned alignment of mutual interests, as politics makes strange bedfellows.
Legislative reform is by definition a reactionary sport. Reforms typically occur after, not before, the proverbial train wreck, plane crash, biblical storm or financial meltdown. Health care reform is no different and in many respects will be much more difficult to achieve, as reformers are attempting to transform the system before it collapses.
While there is overwhelming and growing public and political sentiment that our health care system is in need of some major reform, competing interests are starting to flex their political muscle in order to protect their turf and profits. The zero-sum nature of the current health care debate, in which one group’s gain or loss is balanced by the losses or gains of other groups, has the very real potential to stall out initiatives in the public policy arena.
Don’t count on the HMOs, medical malpractice lawyers, medical device manufacturers, hospitals or some other time-honored antagonist to wake up, hold a press conference, and in so many words pronounce, “all this time we were wrong and the medical profession was right. We’ll change everything and do it your way, starting today.” Then the Red Sea parts and family physicians lead their colleagues and policymakers to the promised land—or vice versa.
So it wasn’t exactly revelatory to me when a lengthy article in The New Yorker by physician-author Atul Gawande dropped the Dartmouth Atlas bomb on top of McAllen, Texas to conclude that (gasp) there are significant variations in per capita expenditures and medical utilization across the country. Gawande’s diagnosis caught all the symptoms out in the open, along with some embarrassingly candid commentary, but a three-day tour wrapped around a statistical analysis comparing the Rio Grande Valley to El Paso, Grand Junction and the Mayo Clinic, precluded him from taking a full case history and physical.
The fact that the article has caught fire and is being waved around the halls of state capitols—and according to The New York Times, the Oval Office—should be measured as a symptomatic manifestation that Congress is embracing evidence-based rather than faith-based health care policy options.
Politics and health care policy are for once in a very long time catching up to each other. The urban myths and sacred cows that have tied health system reforms to a stake are going the way of the dinosaur. For the first time there is a consensus in Washington, and arguably in Austin, that the evidence and science points to primary care as fundamental to reform.
Never mind a couple of decades of studies and warnings about primary care’s negative glide path, and the counterintuitive if not hostile policies—particularly payment policies—that have been layered in and piled on. Political opinion has “discovered” that reforms must be approached as systems, not interests, and it is all predicated on a foundation of primary care.
Exhibit A: The Texas Legislature took the first step toward rebuilding our dwindling primary care workforce by retooling Texas’ physician education loan repayment program for primary care physicians and funded it longterm by closing a loophole in Texas’ smokeless tobacco tax. More than 225 physicians per year will be eligible to receive loan repayment of up to $160,000 for serving in a health professional shortage area of the state. Within four years, the program will be sending more than 900 physicians to underserved communities.
When researchers dig through the archives, they’ll wonder how TAFP, Philip Morris, the Texas Association of Community Health Centers (FQHCs) and the Texas Association of Business pulled with the same set of oars to overcome a raging sea of opposition to pass this historic legislation. The bill survived nine points of order over the course of five days, probably approaching something of a record for death-defying political acts.
The legislation would have died without the execution of the fundamentals of lobbying: grassroots blocking and tackling, steadfast work of the coalition, overwhelming public and media support, and of course the passion and commitment of the bill sponsors, along with their parliamentary skills.
The bill sponsors came from opposite ends of the political spectrum, and drew strong support from their colleagues on both sides of the aisle. Even the Texas Association of Business, often an antagonist to medicine, wrote and spoke publicly about the need for primary care as elemental to restoring affordable, high-quality coordinated care.
Exhibit B: There is renewed interest and broad support to reduce unnecessary administrative costs currently strangling primary care practices. TAFP working with the Texas Association of Health Plans set aside our philosophical differences in health care policy to pass agreed-to legislation requiring all health plans to provide instant, electronic verification of eligibility, benefits and patients’ financial responsibility.
Even America’s Health Insurance Plans recently offered to support a national mandate to standardize and automate five insurance functions: claims submission, eligibility, claims status, payment and remittance.
You have heard me preach over the years that legislative success is all about “the set-up” and that politics drives the process that sets policy. Mastery of all these is required to change legislative opinion and it would appear that politics and policy are drawing closer together around the principles of primary care. Congress could look at our playbook to see a case study or two on how those politics converged as historical differences were set aside for a greater good.