Emotions are still raw from our nation’s year-long debate on health reform. So igniting another quarrel over health care legislation is an unsavory thought.

But we must.

When President Obama in March signed the Patient Protection and Affordable Care Act into law, it was but a first step. Congress saw that our nation’s expensive, patchwork arrangement of providing care was unsustainable. So Congress took steps to reduce the number of uninsured, protect those with pre-existing and high-risk conditions, heighten focus on cost-effective care, and accelerate use of electronic health records.

But we need considerably more action from Congress, and quickly.

That’s because the new law ignored fundamental economic and public-health issues. The law is more about exacting concessions from doctors, hospitals and insurance companies to achieve a political victory than it is about laying the foundation for a healthy, financially sustainable system.

These should be next priorities for Congress:

1. Encourage personal responsibility

The reform law places responsibility for better health just about everywhere except where it really must start – with the individual. If we can tax tanning salons, as the law does, we can surely take more impactful steps to encourage personal accountability and connect costs with risk.

For the most part, spreading health care costs evenly across society is a humane and sensible policy. But it must have limits.

Nearly 50 million people smoke, and smokers add $200 billion annually to the nation’s unnecessary health care expenses. So it’s fair for smokers to pay more to fund private and government insurance.

2. Limit taxpayer-funded services

Many experts, me included, don’t see how the math pencils out. Medicare costs are expected to nearly triple by 2020. Under the current plan, Medicaid (Medi-Cal in California) will grow by tens of millions of new beneficiaries. It’s unlikely the nation’s taxpayers can fund this growth unless stricter limits are placed on the menu of covered services.

Preventative care, inoculations, medically necessary surgeries for appendicitis or accidents – these are appropriate for taxpayers to fund. But for other options – cosmetic procedures to risky transplants to Cadillac drugs – it’s appropriate to expect that patients pay their costs.

3. Promote efficient models of care

Congress wants more cost-efficient delivery of care. But so far, the government’s only approach to encouraging efficiency is to choke off reimbursement, supposedly forcing providers to cut costs and focus on prevention.

Problem is, government itself is preventing hospitals and doctors from collaborating and coordinating care. We can be much more creative and efficient, but only if government gets out of the way. In the next reform, Congress must eliminate unfunded mandates and counterproductive laws.

4. Reimburse providers for their costs

In Massachusetts, with a health system similar to the new federal model, nearly all residents are “insured.” Yet access to physicians is a problem, and hospital emergency rooms are clogged. Why? Because the government insurance is underpaying doctors, and their natural response is to limit those patients.

It’s still a free market system. Once providers do their share to collaborate and design efficient patient care, the government must fairly compensate for Medicare and Medicaid services. 
This is especially true for “safety-net” doctors and hospitals, such as mine, that care for high percentages of public-insurance patients. If unchanged, current law could cost us $250 million in reimbursement over the next 10 years. Such cuts place Community Medical Centers and other safety-nets at financial peril.

5. Enact liability reform

Another area neglected by the law is medical liability reform. Today, doctors are actually encouraged to do more tests and procedures than may be medically necessary in order to protect against expensive lawsuits. By one Harvard estimate, 40 percent of medical malpractice lawsuits are meritless, but, coupled with excessive damage awards in other cases, they drive up health care costs by prompting “defensive” medical tests.

It took 45 years from creation of Medicare and Medicaid to reach today’s re-invention point. Let’s finish the job by immediately getting to work on Health Reform, the Sequel.

Tim Joslin is CEO at Community Medical Centers in Fresno. This editorial was published in The Fresno Bee on May 19, 2010.