Perhaps since the conventions are over, we can get on to some issues now. Health care wasn't a big mention in either venue, although the ACC was very actively present with staff and members at both to keep the issue in the forefront. After Congress reauthorizes s-CHIP (they have to do this) next March, I suspect there will be no $$$ left for much else in '09. See, s-CHIP will cost at least $50 billion to keep going. Don’t forget the SGRrrrr comes up again at the end of the year, too. A zero increase (band-aid) patch on that will cost about $30 billion. Add these up, and pretty soon we'll be talking about some real money.

But all the pundits (bandits with an arsenal of bad jokes) say real reform might happen after all as the Iraq conflict abates, and some members of Congress say they would commit to an unprecedented "budget directive" to erase the SGR. Something like that hasn't happened since 1988. But the fact it's being talked about says something about everybody's interest in getting beyond this dead albatross around our necks.

What everybody is talking about in a cash-scarce time, is looking for places to cut excess health care spending! The easiest of all places to do that where the MOST Medicare spending occurs is in academic centers — and the easiest (from a publicly political vantage point) place to cut is training dollars in residencies, fellowships and research. It’s not just imaging that is threatened.

The pundits (definition above) rightly say the action will be in 2010 if it comes. I fully agree with this. Planning for the action will be the job of 2009. But, all of us should keep in mind that some things that are really cheap might still happen in 2009. Physician payment reforms and registry expansions, and quality improvement pilots and projects could all be done for a few (5 – 10) billion dollars. We should be ready. And we also will need to watching out for survival of training, research, and academic centers where uncompensated care aggregates … .

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