Where goeth the 110th Congress?

February 15, 2007
William L. Rich III, MD

Any major changes in health care will reflect the inflluence of moderates on both sides of the aisle.

In general, and in simple terms, Republican health policy has favored large insurers, managed care, and pharmaceutical companies, and it has limited public program spending and lowered product and medical liability. Democrats distrust private approaches to health care, including Medicare HMOs (a.k.a. Medicare Advantage), and support Medicare fee-for-service (FFS) and the expansion of benefits for preventive care under public programs, such as expanding Medicare pharmacy benefits while limiting increases in beneficiary payments.

This will mark the end of massive support of Medicare Advantage plans, which currently are paid 11% more than FFS health savings accounts.

Because Sen. Max Baucus (D-MT) and Sen. Charles E. Grassley (R- IA) have a similar moderate approach with rural health care as a priority, no big change in emphasis is expected in the Senate.

Probably the biggest benefit for the profession is an effect of the distrust Democratic policymakers have for Medicare Advantage. This distrust will benefit ophthalmologists because Medicare HMOs typically pay 25% less for covered physician services than Medicare FFS. From a policy perspective, Republicans have had no burning desire to fix the problems with the sustainable growth rate (SGR) in Medicare FFS, which leads to yearly entreaties to Congress (accompanied by lobbying dollars) for temporary fixes or freezes in payment.

Anything that would benefit Medicare FFS is not consistent with Republican policy of disincentives for physician and beneficiary interest in Medicare FFS. Democrats want to preserve Medicare FFS, but it must be remembered their primary concern is the beneficiary; physicians will benefit only secondarily as a result of the Democrats' strong desire to maintain the popular Medicare programs.

Long-range outlook

What does this portend for our profession? I doubt there will be any long-term fix to the SGR, because the 10-year cost is more than $220 billion.

There may be more support for the MedPac policy wanting to eliminate the SGR, raise the conversion factor 2% in Medicare FFS, and implement widespread physician payment reform that would help stabilize the Medicare FFS program for beneficiaries. While the design of a new payment mechanism along the lines of pay for performance is evaluated, there may be some support for a 2-year fix.

Reauthorization and expansion of the State Children's Health Insurance Program (SCHIP) will be a Democratic priority. This emphasis on expanding services for children may lead to some action on the Vision Care Kids Act (S. 3685 and H.R. 6227).

After years of negotiations, the American Optometric Association, the American Academy of Ophthalmology (AAO), and the Vision Council of America have reached a consensus that would complement state programs-by providing funding in the form of state grants for eye examinations and additional treatment for uninsured children with eye problems.