Republicans have a new, unfortunately politically astute strategy to chip away at health reform. They want to defund the ten-year prevention and public health fund to finance one year of the perennial “doctor fix,” Medicare’s problematic Sustainable Growth Rate rule. Of course, Republicans are promising to let the political sky fall if they don’t get their way. By the sky falling, they mean allowing Medicare’s physician reimbursement rates to fall by nearly 25 percent on December 31.
The idea of tying the doc fix to a partial health reform repeal has legs because it comes with a clear rhetorical message: Congress should not start creating new entitlements without the necessary funding to uphold existing ones.
The fund’s political predicament is really caused by two facts that are the precise opposite of the rhetorical spin noted above.
First, it is not an entitlement. This term has some specific meaning. Individuals deemed eligible for such a program have a legal right to collect benefits. Moreover, states that administer the entitlement would have a legal claim on the federal government for this money. The public health fund is an appropriation, and is thus vulnerable for cutting.
Second, It just isn’t pork.
According to Politico, “One Republican Senate aide quipped that it was a ‘slush fund for jungle gyms’.” Midnight basketball, for little kids, I suppose. The nastiness of that trope provides a tip-off regarding the politics in play here.
Politicians are generally reticent to call out genuine pork, for one obvious reason: Real pork has powerful friends who get snippy when people say something impolite about it. Agricultural subsidies, 529 accounts, the home mortgage deduction, and other tax goodies for yuppies aren’t pork. Needless weapons systems are pork when we talk in generalities. These weapons are less often called that when the proper nouns and Congressional districts are known. We don’t call tax breaks for affluent small business people pork, either. Overpayments to medical specialists and suppliers or to the Medicare Advantage program aren’t pork; it would be rude to say otherwise.
The prevention and public health fund serves critical, but often politically marginal constituencies. It’s really needed right now, especially when the state and local budget crisis leads many states and localities to lay off public health workers, close smoking cessation quit lines, and more. The fund will help finance substance abuse prevention and treatment, efforts to prevent HIV and sexually-transmitted infections, immunization, diabetes prevention and education. How many federal programs provide such long-term value per dollar spent?
I hope that fund buys some jungle gyms, too. Walking around Chicago, I see a fair number of obese kids who could use a nice jungle gym, and a safe park around it to play in. Perhaps that park would resemble the one I suspect that anonymous Senate aide’s own family can use.
Of all the elements of health reform, this fund is one of the less identifiably liberal ones, though it does touch on icky topics such as sex and drugs. On the substance, there’s no reason for this small-dollar item to attract particular conservative disdain. Indeed many Republican health policy proposals emphasize the importance of prevention investments. It’s just a vulnerable target and a chance for Republicans to put a pelt on the wall in their fight against health reform. They may succeed, although I bet almost every Republican health policy expert would privately agree with me that this is bad policy. As Jonathan Bernstein notes in the New Republic, there are political advantages to not caring much about that.
One thing might help: If doctors-the nominal beneficiaries-spoke out against the stupidity of what is being proposed. If they don’t, they might ponder what Republicans will produce for the doctor fix next year.
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I’ve been persuaded that public-health measures have extraordinary value in the long run. California’s successful anti-smoking propaganda is a fine example.
At the same time, it can be very difficult to demonstrate success. My local public health department — in a broke rural county in NorCal — is stocked full of communications coordinators and community coordinators, but just try to get a deputy to respond to a 911 call in under an hour.
Obviously, all depends on exactly what will be funded. It has always been my opinion that the answer to the question of what policy would do most to improve the health of Americans would have much less to do with insurance reform than with provision of effective prevention services such as vaccination and other services such as public clinics and certain proven effective public health services.
My wildest dream here is that no one budges and the annual fix doesn’t get passed. Then maybe we can sit down and have a rational discussion about how to fix Medicare.
My second wildest dream is that Senate Democrats bring up the doctor’s fix in a stand alone bill and let the Republicans vote against it.
Come to think of it, my second dream is more improbable than the first.