There are two likely scenarios for healthcare under a Mitt Romney and Paul Ryan Administration.
"Day one. Job one. Repeal Obamacare.”
- widely distributed Mitt Romney television advertisement
It is easier said than done, even with a Republican U.S. House and Senate.
There are two likely scenarios in a Mitt Romney/Paul Ryan Administration: control of the House and Senate or just control of the House.
Scenario 1 – Republican House, Democratic Senate
Little of substance, outside of powers given to the executive branch, will change because the law will stand. However, the Affordable Care Act gives almost unprecedented, unilateral authorities to HHS and other federal departments to interpret the law, draft regulations, empanel regulatory oversight bodies, and much more. Included is the executive power to grant waivers to public and private entities, which could substantially dilute the negative impact to the medical community and public.
This is where, presumptively, regulations will be pared, eliminated or circumvented with waivers. This would be a favorable outcome for physicians, employers, and the general public. It is favorable to employers because the requirement that an employer must have the same benefit package for all employees, which serves as a strong incentive to pay the tax penalty and throw employees into the public system, will not be fully implemented, maintaining private healthcare insurance as a benefit. It is favorable for all healthcare providers because the public system will likely reimburse below Medicare rates and the fewer in it, the more viable the system.
The problem will still be money. Without eliminating waste caused by defensive medicine, documentation, and expensive regulation, among a host of others which would require legislative approval that would likely be blocked in the Senate, tough executive decisions will have to be made. The likely long-term target will be increasing the age of eligibility for Medicare for people aged 54 and under, investment in wellness and prevention in the mid-term, and a long, hard road until the mid-term benefits are earned.
Scenario 2 – Republican House and Senate
It will still take some time to slow the train, realign the tracks, offload and reload the paperwork. Still, Scenario 1 is likely in the short term and repeal and redo is almost a certainty in 2014.
That presents the real question: Will the redo look like Massachusetts' Romneycare redux? Comparisons are inevitable, but disingenuous.
For example, Governor Deval Patrick (D, Mass.) recently told CNN that “the list of horrors” that Romney said would come from the Affordable Care Act has not materialized in Massachusetts. True, but misleading.
Why? One word: Medicare. States have no control over the program, or access to its assets that Obamacare uses to help to subsidize its cost.
Further, Congress is not a state legislature. Egos, partisan, and special interests are far more likely to hold sway to block any real systemic reform. The country is far more varied and complex than a state, and congressional districts are much bigger and diverse than slices of cities and countryside, making members less accountable.
One similarity is that the Massachusetts plan does not address (and a new federal plan is highly unlikely to either) low hanging, but politically toxic, fruit including, but not limited to:
• Practical conversion from fee-for-service to pay-for-performance, including paying for evidence-based and much less expensive behavioral, nutrition, and exercise therapies to help to prevent and treat a broad variety of ailments;
• Sensible tort reform that protects both providers and patients fairly and equally at a savings of hundreds of billions per year;
• The explosion of suffocating, complex, and counterproductive regulations that add hundreds of billions in cost each year;
• Reinventing an outdated and dysfunctional FDA that demands large investments in time and money while delaying public access to cost and lifesaving technology because the system is clogged by bureaucracy; and,
• A U.S. Patent and Trademark Office so backlogged it takes years to process patents, further denying access to more effective and less expensive technology and pharmacology complicated by patent protection only for those with the resources to defend them.
One ray of sunshine in a Romney-Ryan scenario is that physicians are likely to be able to contribute to the conversation this time. Going back to reliance on a failed system is not an option, but making any meaningful reform appears to remain politically unworkable.
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