Democratic leaders in the last Congress repeatedly urged their wavering colleagues not to “make the perfect the enemy of the good” before close votes on the passage of the Patient Protection and Affordable Care Act.

Carr calls solvency of Medicare "the elephant in the room."

But nearly a year after enactment of the law, it may be time to start moving it beyond “good.”

A majority of participants in the most recent Commonwealth Fund/Modern Healthcare Opinion Leaders Survey supported the overall healthcare law but want either “some minor changes” or “major changes” to its policies.

Martin Gaynor, E.J. Barone professor of economics and public policy at Carnegie Mellon University, saw the survey's most important finding as “the strong support for the health reform act, even if most respondents think it's imperfect and work is still needed.”

A little less than half, or 45%, of respondents called for minor changes, while another 23% of respondents supported the law but with “major changes.” Also, 23% called for carrying out the law “as enacted,” while 9% urged “a different approach” than the ACA.

“The direction set by the Affordable Care Act is supported by most healthcare leaders,” Karen Davis, president of the Commonwealth Fund, said about the survey's major finding. “I was a little surprised given what we see in the public polls.”

Landes: "Leaders have a vested interest" in a centralized system.

However, a critic of the law, Dr. Bruce Landes, CEO of Southwest Physician Associates, was not surprised the leaders' survey had such different findings than national surveys of the public. For instance, a CBS news poll released Feb. 15 found 33% approve of the healthcare law, while 51% disapprove of the law.

“A lot of people who are so-called leaders have a vested interest in seeing this (healthcare system) centralized because that's how they think” they can guarantee profits, Landes said in an e-mail.

Harris Interactive conducted the survey, which focused on views of the Affordable Care Act, between Jan. 3 and Feb. 1.

A total of 203 opinion leaders from the healthcare delivery, finance and policy fields participated in the survey, the 24th in a series designed to gather opinions from healthcare leaders on timely policy issues.

Premium subsidies had the most support among various components of the healthcare law. A total of 68% of participants described it as “very important” for the government to implement the law's public funding of private insurance premiums, while an additional 19% of respondents agreed that insurance premium supports were “important.”

Dr. F. Douglas Carr, medical director of education and system initiatives at the Billings (Mont.) Clinic, in an e-mail described such private insurance subsidies and the future solvency of Medicare as “the elephant in the room,” which tightening finances will require future sessions of Congress to address.

Even as congressional Republicans continue to challenge the law legislatively and state attorneys general challenge its components in court, significant combined majorities of healthcare leaders described implementation of various components of the healthcare law as “important” or “very important,” including state insurance exchanges (86%), the individual mandate (84%) and the Center for Medicare and Medicaid Innovation (83%).

“Healthcare leaders look to the ACA as an imperfect but effective vehicle for changing the healthcare delivery system,” Carr said. “They want to build on it, not dismantle it.”

Also, 82% of respondents identified the law's expansion of Medicaid eligibility to at least 16 million more people as “important” or “very important,” which surprised Dr. Robert Crittenden, a professor of family medicine at the University of Washington.

“Many policymakers attack the use of Medicaid as a building block of” the healthcare law, Crittenden said in an e-mail. “There appears to be broad support for the use of this building block by the health leaders.”

The least popular provision of the healthcare law among survey respondents was the creation of the Independent Payment Advisory Board, which has drawn considerable concern from physicians and hospitals. A combined 71% described IPAB's implementation as either “important” or “very important.”

But even that controversial cost-control measure retained majority support, which showed Davis that healthcare leaders are committed to the approaches contained in the law. “You don't see rejection and hesitancy on the part of the healthcare industry,” she said.

• 91% chose payment systems that improved care coordination for patients with chronic health conditions.



• 66% chose accelerating implementation of the healthcare law's bundled payment provisions for acute and post-acute care.



• 59% chose the use of reference pricing.



• 59% chose revising payment rates to reflect the actual cost of providing physician services.



• 56% chose strengthening the role of state health insurance exchanges to encourage competition and encourage implementation of the healthcare reforms.



• 38% chose allowing beneficiaries to purchase insurance across state lines.



• 22% chose expanded use of health savings accounts and high-deductible health plans.

However, the rising clamor among politicians of both major political parties for aggressive efforts to rein in the nation's ballooning debt—including initiatives aimed at the costly Medicare and Medicaid programs—have not gone unnoticed by healthcare leaders.

Among the cost-saving approaches suggested by various groups—including President Barack Obama's National Commission on Fiscal Responsibility and Reform—healthcare leaders most favored an expansion of cost-saving initiatives created by the healthcare law. Specifically, 81% supported expanding successful cost-containment pilot projects launched by the healthcare law, such as pay-for-performance and post-acute-care service bundling. The next most popular approaches, each supported by 61% of healthcare leaders, would extend the healthcare law's Medicaid prescription drug rebates to so-called dual eligibles or add a “robust” government payer option to state insurance exchanges.

On the contrary, the survey found little support for conservative cost-control ideas, which could affect Republican plans to offer them as an alternative under their “repeal and replace” initiative.

“This is an influential constituency,” Davis said.

The relatively low level of support among healthcare leaders for the public insurance option was not expected by Dr. Robert Tranquada, a retired professor of medicine and public policy at the University of Southern California, according to his e-mailed comments.

“Clearly, the public option would provide a substantial measure of competition to the private sector,” Tranquada said in reference to Medicare's lower administrative overhead compared with private plans. “It seems to me that this would be one of the most effective ways to initiate significant decreases in overall healthcare spending.”

Among the numerous issues Congress is likely to wrestle with beyond the scope of the survey, according to Gaynor, is the fallout of a possible Supreme Court ruling against the constitutionality of the law's individual mandate. Gaynor said other ways to achieve the same goal include automatically enrolling most Americans in “a standardized, basic plan.”

“They could opt out of that plan into another of their own choosing (e.g., their current plan for those who have insurance now),” Gaynor said about a system that sets premiums on a sliding income scale and collects them through the tax system. “In my opinion, this would actually be superior to the individual mandate that's in the act, and shouldn't run afoul of the legal issues that have arisen with respect to the mandate.”

Like many other physicians, Tranquada sees more congressional efforts needed beyond the healthcare law to increase the proportion of medical school graduates who enter primary care.

“Tuition subsidies, increased compensation for services and medical school debt forgiveness are some of the options here,” he said.

Congress also may need to step into the looming battle between the Obama administration and state governments over the possibility that many of them may cut their Medicaid rolls to close persistent budget gaps in the wake of the recent recession, Tranquada said.

Congress and state legislatures have already made “the usual and easy cuts” to control rising healthcare costs, Tranquada said. So Congress will have to provide ongoing support to medical innovation and improvements in healthcare as “essential system changes” and the only real hope to taming the accelerating costs of those public insurance programs.