come back of republicans

November 3, 2010 — American voters last night gave the House of Representatives to Republicans, let Democrats stay in charge of the Senate, and left physicians wondering what a divided Congress will do about healthcare reform and Medicare reimbursement.

The November 2 midterm election gave Republicans and its Tea Party wing 239 of the 435 seats in the House of Representatives as of this morning — a net gain of 60 seats. Thirteen House races are still undecided. The GOP fell short of taking over the Senate, but nevertheless upped its number of seats there from 41 to at least 46, with the races in Colorado, Alaska, and Washington still in contention.

Their resounding triumph in the House gives Republicans a stronger position to pursue their stated goal of repealing the healthcare reform law known as the Affordable Care Act (ACA), or at least portions of it. House Republicans have already promised not to appropriate funds to implement the law. In addition, Republicans will assume chairmanships of House committees by virtue of their majority, giving them more leverage to oppose reform efforts by the Obama administration.

Rep. Joe Barton (R-Texas), for example, is expected to head the House Energy and Commerce Committee, which has jurisdiction over healthcare legislation and the US Department of Health and Human Services. Before the election, Barton had served as the committee's ranking Republican. In an op-ed piece published last week in the Washington Times, he vowed to conduct hearings on how the Obama administration and Congressional Democrats have promoted and implemented healthcare reform. "Our first job will be to find out what's gone wrong," he stated.

The Republicans will now flex their muscle in the House, but they will have to operate in the reality of a politically divided government. Any bill they pass can be voted down by a Senate still in Democratic hands. If Republicans find enough Democratic allies in the Senate to pass legislation undoing the ACA, President Barack Obama will undoubtedly exercise his veto power. At the same time, a Republican House can block any bill emerging from the Senate, and there, Republicans command enough votes to filibuster any Democratic bill.

Congress could still produce legislation, of course, if Republicans and Democrats turn to bipartisan cooperation. However, legislative experts in organized medicine interviewed by Medscape Medical News last week warn of continued political gridlock that could frustrate efforts to achieve a permanent solution to the Medicare reimbursement crisis.

Physicians face a massive cut in Medicare reimbursement on December 1, and a smaller one on January 1 that will add up to 24.9%, unless a lame-duck Congress later this month acts to avert it. The cuts are triggered by Medicare's sustainable growth rate (SGR) formula for setting physician pay. The Congressional Budget Office has put the price of replacing the SGR formula with one considered more equitable for physicians at more than $300 billion.

In a press release issued today, Cecil B. Wilson, MD, president of the American Medical Association (AMA), promised to work with both parties in the new Congress to solve the Medicare reimbursement crisis.

"There is broad bipartisan agreement that the Medicare physician payment system is broken, and the AMA will work with the 112th Congress to enact a permanent solution and protect access to care for seniors and baby boomers," Dr. Wilson said.

Muddled Message on Healthcare

For physicians, the main result of the election is uncertainty, said Robert Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians (ACP).

Doherty pointed to an exit poll conducted by the Washington Post and ABC News showing that 62% of voters last night viewed the economy as the most important issue facing the country, with only 18% ranking healthcare that high.

"It's a mandate of dissatisfaction with the economy, but it's hard to read a strong mandate on healthcare," Doherty told Medscape Medical News.

That same poll also revealed a public nearly split down the middle on the ACA. While 47% of voters want to repeal the law, another 47% want to either leave it as is or expand it. "Voters gave a very muddled message when it came to healthcare reform," noted Doherty.

Like other observers, Doherty predicts that the ACA will remain basically intact, at least through 2012, when the nation elects a new president. "Even with their big win in the House, Republicans won't have enough votes to repeal major parts of the law," he said.

Jack Lewin, MD, chief executive officer of the American College of Cardiology (ACC), makes a similar assessment.

"This election was about jobs and the economy," said Dr. Lewin. "It wasn't about healthcare reform. But physicians and the healthcare system will be caught up in what this movement means, which is about capping government spending and reducing deficits.

"So basically there will be some negatives for physicians," he said. "Congress will be in gridlock on most issues. The president won't be able to do anything bold. The ACA will remain in place and gradually be implemented."

The heavier spirit of frugality in the nation's capital, Dr. Lewin added, reduces the prospects for any long-term solution to the Medicare SGR problem.

"I hate to be a pessimist, but I can't believe Congress will be able to come up with $300 billion to fix the SGR," he said. Republicans will insist on taking the necessary funds from some other part of the budget, and Democrats will likely resist.

Physician Opponents of ACA Cheered by Election Results

Several major medical societies such as the ACP supported the ACA. One group that did not was the Coalition of State Medical and National Specialty Societies, which represents some 85,000 physicians. Coalition spokesperson M. Todd Williamson, MD, a neurologist from Lawrenceville, Georgia, said last night's election results were heartening.

"I think it's a very positive prospect," Dr. Williamson told Medscape Medical News. "There's a perception among a lot of physicians that this (election) represents a rejection of the healthcare reform law. We opposed the ACA because, in a nutshell, it puts too much government between the patient and the doctor. It makes healthcare a business of the federal government."

Dr. Williamson said his group would continue to lobby Congress for what it considers to be the "first bite" of healthcare reform — the right for any physician and any Medicare patient to privately contract on prices for services, regardless of what Medicare pays. This right would allow physicians to receive payment from Medicare and balance-bill patients for the remainder of their charge. The AMA also has endorsed this measure.

Dr. Williamson said private contracting would allow Medicare to curb what it spends on medical services while allowing physicians to charge what they need to stay in business.

"Private contracting is the way we do business in this country," he said.

Physicians Hope New Congress Tackles Tort Reform

For physicians, one positive in the election results is the possibility of victorious Congressional Republicans prescribing one of their favorite reforms for healthcare — tort reform. The cornerstone of tort reform in the eyes of physicians and Republicans alike is a cap on noneconomic (pain and suffering) damages awarded to malpractice plaintiffs.

Dr. Lewin said that although House Republicans may make headway on tort reform, Senate Democrats are likely to stand in the way because they are leery of caps on noneconomic damages. "But we'll get it passed anyway," he said.

In his statement today, AMA President Dr. Wilson said the new Congress should put tort reform on its agenda. Dr. Williamson of the Coalition of State Medical and National Specialty Societies also urged action on tort reform.

"It could save real money for the federal government," he said. "So much of what we spend on healthcare is for defensive medicine."