How Will a Divided Congress Impact Healthcare Reform?

Jeffrey A. Lieberman, MD


November 09, 2010

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Hello. This is Jeffrey Lieberman of Columbia University for Medscape. There's an old proverb that says, "may you be cursed to live in interesting times," and that certainly is the case for us today. Here we are, a few days after an election where we're going to see, as a result, a massive change in government, changes within Congress, within the Senate, within state legislatures, and within the gubernatorial offices of a variety of states. The implications in terms of healthcare policy and mental healthcare policy and the practices and activities of psychiatrists and mental healthcare providers are, to a considerable degree, unknown. I would like to offer some speculations on the consequences of these electoral changes and what the future may hold with respect to our field, our profession, and our activities in caring for patients.

First, we have for some time been living under the spectre of potential changes in the context of healthcare reform. We don't know what is going to happen as a result of these elections. Republicans have stated that they are committed to repealing -- changing substantially, if not repealing -- the Healthcare Reform Act. We don't know what this means. Does that mean that the universal coverage provision will be modified or eliminated? Does it mean that the prospect for tort reform may be changed? Does it mean that there will be alterations in quality-based reimbursement, which is where the field of healthcare and the regulatory environment seem to be headed -- that is, reimbursing hospitals, reimbursing healthcare providers on the basis of their performance and quality measures? Also, we now are facing the likelihood that the government will establish a new agency and funding stream to support comparative and cost-effectiveness research -- that is, research looking at the comparative effectiveness of marketed treatments, and also to evaluate their cost effectiveness in this context. So, all of these things have the prospect of producing marked changes in our lives, in our daily activities, and in our professional practices, but we're not sure exactly how these are going to be carried forward (or not) given the massive change in the government that has just taken place.

There are also implications for the National Institutes of Health (NIH) and the funding of research that historically has fallen to the NIH. The NIH, after the doubling of its budget, has been receiving pretty much flat budgets with modest increases over preceding years. It received a substantial boost with American Recovery and Reinvestment funds in the context of the stimulus plan. Those funds will run out this year, and the question is whether there will be any kind of supplementation of the National Institute of Mental Health budget to replace this incremental funding, or whether the NIH budget will fall off a cliff, so to speak. If so, then pay lines for research will go down markedly, and the pace of scientific discovery and advances in research will diminish as a result, until the budget recovers.

In addition, something that is particularly punctuated, given the change in the government after this recent election, is the fact that healthcare, in general, and particularly mental healthcare, needs to have champions in Congress. Now, historically, mental healthcare has benefited from the heroic efforts of champions like Pete Domenici, John Porter, Arlen Specter, Patrick Kennedy -- who will be retiring from his congressional office after his term expires, and Jim Ramstad, Patrick Kennedy's partner in sponsoring the mental healthcare parity legislation, who also retired from office over a year ago. So, these historic and current champions are leaving Congress, and we don't know if anybody is going to replace them. We need to cultivate champions for mental healthcare in Congress, and that's something that we can do at the local grassroots level or through our professional organizations, and organizations like the American Psychiatric Association particularly need to play a role.

All of this uncertainty (and certainly there are many reasons to be concerned, if not worried) is real and can't be avoided. At the same time, on the bright side, there are many things to be heartened about. Medicine, healthcare, mental healthcare, and psychiatric medicine are a safe haven. Our country and society needs them. This is not an industry that can be outsourced, exported, or phased out. Information technology cannot replace what we do. There will be greater demand than ever, particularly given the recognition of the need to provide coverage for people who are currently uninsured. In addition, our profession as healthcare providers and psychiatric physicians is something that we can feel good about. You can get up every day and feel good about what you are doing, contributing to our society and humankind. It also would be nice to get paid for it in a reasonable way, but that will require trying to figure out how to improve our healthcare financing system. Scientific progress will also continue, and whatever the funding level of the NIH turns out to be, a slower rate, or an accelerated rate, we'll still have scientific advance, which will improve the quality of care in the future. Eventually, if not sooner, then later, I am confident that we will figure out a way to sort out the complexities and inefficiencies of our healthcare financing system because much of what is unpleasant and difficult and inefficient about medicine and healthcare delivery has to do with the dysfunctionality of our healthcare financing system. But, perhaps the change in government will help that rather than not address it or make it worse. We can always be hopeful.

That's my message for today. This is Jeffrey Lieberman of Columbia University for Medscape.


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