This is being written in September, before Americans choose a new president and Congress, as Congress labors to curb panic in financial markets by invoking two thirds of a trillion taxpayer dollars to protect lenders, but not borrowers, against defaults, foreclosures, and bankruptcies. The new leaders will confront the urgent problem of digging out of the holes left by the Bush administration.
This is not unique. But by contrast, Bill Clinton left George Bush a booming economy, a balanced federal budget, and even reductions in the national debt. Less than a year later, with 9/11, a slowing economy, and a desire to reduce taxes, the federal government was back on the deficit side of its affairs, and it has stayed there.
This spending will make more difficult solving the nation’s health care problems. When Congress rejected Bill and Hillary Clinton’s 1993 health reform package, President Clinton made no further efforts in that direction. The single Bush initiative was the 2005 enactment of a bill that added mixed pharmaceutical benefits for Medicare patients and a strongly subsidized incentive for health care insurers to offer Medicare Advantage, a new package of managed care plans. The guaranteed payments to drug makers and the insurance industry are conceptually akin to the recent approach to banks and brokerages.
Health care dilemmas are familiar ones. Despite crude curbs on spending, annual increases in health care costs have climbed back to double digits. Health educators predict that restraints on medical school classes will result in doctor shortages. Some insist that the shortages will fall most heavily in primary care. But they have not looked at the situations in radiology and pathology. One reason why other physicians dabble in medical imaging is that there have never been enough radiologists to meet the ever growing demand for their services.
Medicare figures indicate that Part B payments to physicians amount to one dollar in five for imaging services. The rapid growth in imaging in other disciplines accounts for much of the increase. This problem was the focus of a part of House Resolution 6331, the law passed last July that deferred a 10.6% reduction in Medicare payments to all physicians. The part affecting imaging services places new requirements on any physicians who want to get into the imaging trade. We can hope that this approach will be more effective than the two Stark bills, which sought to impose restraints on self-referred imaging. However, the new requirements will not take effect until 2012, providing time to create loopholes.
In the inflationary 1970s, state and national health planning requirements were imposed to restrain the growth of hospitals and the acceptance of expensive devices, such as computed tomographic scanners. I recall one Massachusetts planner promising that planning would “kill the CAT.” Just the opposite happened. The value of computed tomography and subsequently magnetic resonance imaging was so obvious that the planners had to back away. Radiologists successfully argued that using computed tomographic scanning as a primary imaging procedure was more medically efficacious and cost effective than regarding it as the tertiary resource if all other imaging failed. When this example was multiplied, planning generally was not successful in cutting costs. The obvious effect was to push physicians out of hospitals to avoid the planning process. Surgicenters, imaging centers, freestanding emergency clinics, and even health services in supermarkets grew and added to costs.
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