Health Care Reform 2009: Implications for the Clinical Laboratory

Now that the economy appears to be stabilizing, healthcare reform has emerged as the top domestic issue for Washington policymakers. Both the White House and Congress are actively engaged in crafting legislation to cut overall healthcare costs and expand coverage. The goal is to pass and sign into law a final House–Senate reform package before the end of the year. The good news for healthcare reform advocates is that there is general agreement among all parties that the current system needs to be overhauled. The bad news is that there are many contentious issues that could derail the process and make 2009 a repeat of 1993—the last time lawmakers took up comprehensive reform. Reform advocates seem to be in a stronger position than before, because many of the congressional health committees have been working on this issue for the past 2 years and there seems to be a consensus to move ahead. In addition, President Obama is taking a pragmatic approach, indicating that he is willing to work with congressional Republicans to get bipartisan support. Enacting healthcare reform won’t be easy, however. Since the 1930s, 6 Democratic Presidents, often with larger Democratic congressional majorities, have failed to pass comprehensive health reform legislation. Only Lyndon Johnson, in the aftermath of John F. Kennedy’s assassination, was able to enact substantive health reforms, such as the creation of the Medicare and Medicaid programs. Equally, if not more important than large Democratic majorities, are the views of key health interests, such as insurers, hospitals, and physicians, along with business and labor groups. Each of these political actors can influence public and congressional opinion, and their level of support or opposition to reform may influence the outcome. So what are the key points of contention that could make or break healthcare reform? One key area of dispute is whether to include a public insurance plan, otherwise known as the “public option”, in the final package. Democrats argue that a government-directed plan would ensure consumer choice and spur competition. Republicans assert that government intervention would unfairly distort the marketplace, and their support hinges on whether such a plan is included in the final bill. A compromise on this item will be critical to garnering bipartisan support and final passage. Another area of disagreement is how to finance the nearly 1 to 2 trillion dollars needed to fund many of the suggested reforms. Proposals that would remove or limit charitable deductions and tax employee health benefits have not proven popular, leaving lawmakers to scramble for mechanisms beyond eliminating waste, fraud, and abuse to pay for reform. A problem for reform advocates is that any proposals that raise taxes and/or cut provider payments serve only to increase opposition to change. Related to the cost issue is whether to extend health coverage to all uninsured Americans immediately or take a more gradual approach. Although lawmakers and the public voice support for providing immediate coverage to the 46 million uninsured, support begins to wane as the financial costs and the budgetary trade-offs become more evident. The coverage and financing provisions are inexorably linked, and the shape of the final package will depend on how and whether these considerations are resolved. For the laboratory community, reform has the potential to increase the volume of testing, particularly if the uninsured are brought into the healthcare system, and testing is included in both the basic benefits and preventive services packages. Evidence-based medicine may also gain a boost, as lawmakers continue to promote comparative effectiveness research as a means to improve clinical decision-making and reduce overall health expenditures. Clinical laboratories, like other health providers, need to be concerned about the inclusion of payment cuts as a means of funding reform. On a positive note, competitive bidding is unlikely to end up in the final package given that Congress went on record last year opposing it when they repealed the government’s authority to conduct a pilot project involving clinical laboratories. Although the adoption of a copayment has garnered some attention because it would significantly impact beneficiaries, it may be passed over as well. Where laboratories are most vulnerable is the annual consumer price index update. This has been the congressional cut of choice for the clinical laboratory community for more than 20 years, with laboratories rarely getting a full update or any update at all. Although the clinical laboratory community has succeeded in recent years in forestalling new cuts, it is unlikely that any provider will escape without some fee reduction as part of reform. If President Obama and Congress are going to enact healthcare reform legislation, it will have to happen this year. Next year is an election year and many legislators will be hesitant to support a bill, given the hard choices required and the potential magnitude of the changes, both in cost and scope. The outcome of these deliberations and what short- and long-term implications they will have for clinical laboratories should become more evident in the coming months. Author Contributions:All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approval of the published article. Authors’ Disclosures of Potential Conflicts of Interest:No authors declared any potential conflicts of interest. Role of Sponsor: The funding organizations played no role in the design of study, choice of enrolled patients, review and interpretation of data, or preparation or approval of manuscript.