The ACP Advocate Blog
by Bob Doherty
Tuesday, December 3, 2013
Why I Fight for Obamacare
Readers of this blog and my tweets know that I am a passionate advocate for the Affordable Care Act, or Obamacare if you prefer. It isn’t that I have a Pollyannaish view of the law itself, or the tortured political process that produced it—far from it. The ACA is an imperfect law, created by imperfect people through an imperfect process, with imperfect results. After almost 34 years of experience in Washington advocating with Congress and federal agencies, no one needs to tell me about the difficulties involved in successfully legislating and implementing the kind of sweeping changes required by the ACA.
Yet, I will continue to fight for successful implementation of the Affordable Care Act, warts and all, and against efforts in Congress or by the states to undermine, block, defund or repeal it. Here’s why:
First, my employer, the American College of Physicians, supports the ACA, and I am professionally obligated and personally committed to doing everything I can do to advocate for the policies established by our Board of Regents. If I was unable or unwilling to advocate in support of the ACA, I would seek different employment.
Second, and more to the point, I am proud to work for a physician organization that has championed the cause of universal health insurance coverage for more than two decades now, and which today views the ACA as the best chance this country has had to ensure that nearly all Americans will have access to coverage. That the College would be in favor of a law that has the potential to expand coverage to up to 95% of all U.S. resident should have come as no surprise to anyone who has followed ACP policy.
In May, 1990, ACP said that, “A nationwide program is needed to assure access to health care for all Americans, and we recommend that developing such a program be adopted as a policy goal for the nation. The College believes that health insurance coverage for all persons is needed to minimize financial barriers and assure access to appropriate health care services.”
In 1992, the College editorialized in the Annals of Internal Medicine that, “No one should go without medical care for lack of money. As physicians, we struggle daily against the chaos of illness and injury, whether in the context of clinical, laboratory, or administrative practice. We try our utmost to restore or to preserve health, yet the lack of access to care for many Americans increasingly frustrates our best efforts. In this issue of Annals, the American College of Physicians proposes a plan to ensure high-quality care for everyone.” The editorial was accompanied by a policy paper that proposed specific policies to achieve universal coverage.
ACP later went on to support the Clinton health care plan, and after that plan failed to get through Congress, promoted incremental steps to expand coverage. Then, in 2002, ACP proposed its own plan to get everyone covered through tax credit subsidies to buy private health insurance plans offered through state marketplaces and by expanding Medicaid to everyone below the federal poverty level (sound familiar?), phased in over seven years. ACP’s plan was the basis of bipartisan legislation introduced in consecutive Congress’s by Senators Jeff Bingaman (D-NM), Steve LaTourette (R-OH), and Marcy Kaptur (D-OH). ACP’s proposal was updated in 2008 to recommend giving the states more options to develop their own plans for universal coverage. Then, in February, 2009, ACP called on newly elected President Obama and the 111th Congress to “provide affordable and accessible health care to all Americans.” On January 15, 2010, ACP offered Congress detailed recommendations on the bills making their way through Congress to deliver on President Obama’s commitment to enact guaranteed coverage for all Americans, which later became the Patient Protection and Affordable Care Act (Affordable Care Act). One month before the ACA became law, ACP issued a statement of overall support for the bill, citing the many specific policies in it that were aligned with the College’s own policies.
The version of the Affordable Care Act that passed Congress a month later was almost identical to ACP’s own proposals, going as far back as 2002, to expand Medicaid to all persons at or near the federal poverty level, to require that large employers provide coverage, and to provide tax credit subsidies for people to buy qualified coverage through state-run marketplaces.
So why, then, do I fight for the ACA?
Because it is the position of the American College of Physicians—developed over many decades of analysis, and consensus--that every American should have guaranteed access to health insurance coverage, no matter where they work or live or how much they earn.
Because universal coverage is a moral and medical imperative.
Because the ACA comes close to providing universal coverage.
Because the ACA’s key policies, including tax credits to buy qualified health plans and Medicaid expansion, are identical to the College’s own proposals.
Because if the ACA fails, we will have turned our backs on the tens of millions of our fellow Americans who are at greater risk of living sicker and dying younger, simply because they lack health insurance.
Oh, and one more thing:, this is personal. I have spent my entire professional life fighting to expand coverage for the uninsured, only to see it fail, time and time again, because of unrelenting political and ideological opposition. I first started working as an advocate for internal medicine at the American Society of Internal Medicine in January, 1979. Since then, I have seen the cause of universal coverage fail under successive administrations and congresses. I have seen it fail despite all of the well-meaning reports and commissions that challenged us to do better. I have seen it fail as the number of uninsured has grown, year after year, decade after decade. I lived through the debacle of President Clinton’s failure to achieve universal coverage, and then I saw it put aside for another 16 years, until President Obama vowed to try again. I lived through the contentious debate preceding the ACA’s enactment in March, 2010. I am living through the ongoing political wars to block, defund, or repeal it. I am living through the challenges created by the law’s troubled implementation.
But if I have any influence whatsoever, I am not going to watch it fail this time, not when we are so close to providing affordable coverage to nearly all Americans, the moral and medical imperative described by the American College of Physicians almost a quarter century ago.
Today’s questions: Is the ACA worth fighting for? Why? Or why not?
Tuesday, November 26, 2013
Guess what! Obamacare is working . . .
…quite well, in some places, for quite a large number of people. But you wouldn’t know that from the constant media drumbeat about the problems with the www.healthcare.gov enrollment portal and the relatively small percentage (fewer than 6%) of the population whose individual insurance policies have to be replaced because they don’t meet the law’s benefits and ratings standards.
Now, before I get a rash of comments about how I can be so naïve about the problems with the Obamacare launch (I know, I will probably get them anyway), let me state from the outset that it is inexcusable that the administration launched an enrollment website, www.healthcare.gov, that clearly was not ready. It is completely inexcusable that a toxic combination of poor management, politics, under-performing contractors, and an apparent complete lack of transparency and accountability resulted in such a chaotic launch. It is also clear that the President’s promise—“if you like your health plan, you can keep it”—was false.
The website problems, the cancellations, and Obama’s broken promise have led to weeks of negative news stories about Obamacare. Support for Obamacare has fallen as result, although most Americans do not want it repealed.
Some have pointed to the roll-out problems as evidence that Obamacare is fundamentally doomed because, as Bill O’Reilly claims, “the federal government is not capable of running the health care system.”
But the fact is that Obamacare already is working as it is supposed to in many states. Just look at California and Kentucky. California is a “blue” (reliably Democratic) state that is so large that it often is a national trendsetter, although it also is the state with the biggest numbers of uninsured behind Texas. Kentucky is a small, poor, southern state that votes “red” (reliably Republican) in presidential elections, although it has a conservative Democratic governor and legislature. They couldn’t be more different, except when it comes to the ACA: both states are fully on board with Obamacare, and both are having very promising initial success in signing people up.
Kaiser Health News reports that as of November 19, 80,000 people had signed up for coverage in California’s ACA marketplace, and nearly 23% were between the ages of 18 and 34, which “more or less matches their makeup statewide.”
Kentucky’s rollout also is going smoothly. The Washington Post published a striking account of the poor, rural Kentuckians who are signing up in droves for ACA coverage, and what it means for them and their families. “If the health-care law is having a troubled rollout across the country, Kentucky — and Breathitt County in particular — shows what can happen in a place where things are working as the law’s supporters envisioned,” writes Post reporter Stephanie McCrummen. She tells us about Courtney Lively, “who has been signing people up since the exchanges opened in early October.” Lively told her that, “people have been ‘pouring into’ her office” and “one woman cried when she was told she qualified for Medicaid under the new law.”
But it isn’t just California and Kentucky where Obamacare enrollment is picking up. The fourteen states running their own marketplaces are reporting an “enrollment surge,” doubling enrollment to about 150,000 from 79,000, according to state and federal statistics.
So if Obamacare is fundamentally unworkable, as it critics claim, then how can it be working in California, Kentucky and most of the other 12 states that are running their own ACA marketplaces? And if it isn’t working so well, so far, in the remainder that are being funneled through the troubled www.healthcare.gov website, isn’t that at least partly the fault of the governors of those states that chose not to set up their own marketplaces, leaving it to the feds to do the job for them? And if the federal government fundamentally is incapable of running a health care system, then how do we account for the fact that it has been successfully running Medicare for 48 years now, and very few Americans (even die-hard conservatives) are in favor of ending government-run Medicare as we know it?
It would take Rose-colored glasses to not see that the federal government’s incompetence in rolling out the www.healthcare.gov web portal has been nothing short of disastrous. But one would have to be blinded by ideology to not see that Obamacare is working the way it is supposed to in California, Kentucky and many other states, signing up tens of thousands of people who otherwise would be without affordable health insurance coverage.
With apologies to New York City and Frank Sinatra, if Obamacare can make it there (in California and Kentucky), it can make it anywhere. Once the feds get that darn www.healthcare.gov website fixed, that is.
Today’s question: What do you think the promising rollout of the ACA in California, Kentucky and most of the other states that are running their own marketplaces bodes for Obamacare?
Friday, November 8, 2013
Is it “paternalistic” to set minimum standards for health insurance?
Dr. Bob Centor, author of the always provocative and thoughtful DB’s Medical Rants, suggests that the deep divide over the Affordable Care Act is based on “a major philosophic disagreement” over the respective roles of government and of individuals in choosing what is best for them:
“The administration and their supporters believe that government’s job is to protect citizens from their bad choices. They want to decide what the people need and thus impose regulations. The opposition wants the right to make their own decisions about what defines good insurance.”
(Disclosure: Dr. Centor is chair-elect of the ACP Board of Regents, although his blog posts are his own personal opinions, not ACP policy. I, of course, work for ACP, as its senior staff advocate on public policy.)
He goes on to cite a New York Times editorial supporting the cancellation of substandard policies, and suggests that, “This editorial, and the law in general, take a paternalistic view of health insurance. This is the philosophical position that defines the problem. The response to policy cancellations and marked increased insurance costs is typified (in the New York Times editorial]..This represents the current talking point – bad insurance. But who should determine what defines bad insurance?”
Is it really paternalistic for the government to set minimum standards for health insurance? Paternalism means that someone—in this case—the government, is second-guessing the choices that I might make for myself and my family, because it believes that it knows better than me. But is that what is really going on with Obamacare’s minimum standards for health insurance?
Of course, taking bad products off the market does limit my individual choices. But the real purpose of Obamacare’s essential benefits and consumer protection standards is to regulate practices by the insurance industry that can cause direct and indirect harm, both to insured persons who is stuck with a bad plan, but also to the rest of us. The regulations are designed to ensure that insurance companies no longer profit by selling insurance on the individual market that is deceptive and often unsafe and harmful. The regulations are designed to end the insurance industry’s systematic cherry-picking of who they choose to insure, pitting the healthy against the unhealthy.
How is this any different than the government imposing product safety standards in so many other areas, and appropriately so? Automobiles that don’t meet federal safety standards—seat belts, air bags, and protection from front end collisions—can’t be sold by auto manufacturers. Sure, there are “grandfathered” used cars available that don’t meet such standards—fewer and fewer of them as time goes by—but cars sold after such federal standards were mandated have to comply. Is reducing the number of Americans killed because manufacturers sold them unsafe cars—remember Ralph Nader’s Unsafe at Any Speed book, which started the modern consumer protection movement in the United States—motivated by paternalism? Perhaps in the sense that the federal safety experts understand that drivers will make mistakes. The federal safety standards, though, make it far less likely that we will pay for our driving mistakes (and the mistakes of other drivers on the road with us) with our lives.
And yes, by requiring that cars have mandatory safety features, the federal government is forcing us to pay more for them—even features we might think we will never need. I have been fortunate in my almost forty years of driving to have never had a collision with another vehicle, other than being rear-ended twice by another car (both at low speeds when my car was stopped, and neither seat belts or air bags come into play with rear end collisions). But I am sure glad that because of government regulation all of my cars have seat belts and airbags, because you never know, they might save my life, or my wife’s or children’s lives.
Is it paternalistic for the government to regulate the safety of our food? Henry Aaron, a highly respected expert on health care policy, compares Obamacare’s health insurance standards with the federal government setting food safety standards:
“Imagine a new law enacted to promote food purity. As it is being debated, you are told: ‘If you like what you eat, you can keep on eating it.’ The new law takes effect, and one day, you find that the market no longer carries certain foods you have been buying. As it happens, those products included elements found to be bad for your health. The pure food act barred their use. Obamacare is analogous to the pure food law. It bars certain common practices of insurance companies that most people find unacceptable at best, outrageous at worst.”
Or take today’s announcement that the FDA proposes to ban Trans Fats in food because of the evidence that they cause deaths and disability from preventable heart disease. Is this paternalism? It does involve the government inserting its judgment into what foods can be sold to us, limiting the choices of what we can eat. (Although I suppose we could “grandfather” our favorite prepared pastries made with Trans Fats by stocking up on them before they are banned.) Or is this just another case of necessary and appropriate regulation to protect lives?
There certainly are other government policies that come closer to paternalism, because they limit our choices directly, not just what can be sold to us. Take cigarettes—they can be legally sold to adults, but the government mandates warning labels because, well, they and we know that some of us will choose to inhale carcinogens that might sicken or kills us, and when we do, we impose costs on everyone else. Or take state laws that require that motorcycle riders wear helmets—a direct mandate on individual riders that requires that they spend money on something they might not want or feel they need, but that will help keep them alive (and keep them from shifting their health care costs to everyone else if they end up hospitalized from an accident). But most of us, physicians especially, would agree that these mandates are a reasonable exercise of government regulation.
This brings me back to Obamacare’s regulation of health insurance. The standards prohibit the sale of health insurance policies that can cause great harm because they deceptively leave people exposed to bills that can bankrupt them. They prohibit insurance companies from turning down or canceling coverage because they get sick. They prohibit cherry picking, signing up healthy people at a discounted premium at the cost of charging more or denying coverage to the less healthy. They require that insurers cover ten essential health care categories, not exotic or unnecessary things, but the basics--like prescription drugs, hospitalizations, doctor visits and preventive services, not because the government thinks it knows better than me, but because these are the benefits that evidence shows are effective in improving outcomes. Because if your insurer doesn’t cover them, and you get sick, hospitals and doctors will treat you anyway, but your “uncompensated” care costs will be shifted to the rest of us. And you will probably go bankrupt in the process.
They mandate that the benefits be pegged to “benchmark” plans in each state offered by large employers or to state government employees, ending the benefit discrimination that now exists against people in the individual insurance market. They end discrimination against women, by requiring all plans to offer maternity coverage, instead of excluding it from coverage (as is often the case now) or requiring women pay more to get it. (As far as the argument against requiring men to pay for maternity coverage, well, it isn’t as if women get pregnant on their own, as one women physician tweeted to me a couple of days ago.)
Washington Post columnist Ruth Marcus reminds us that Obamacare is trying to remedy a marketplace for insurance that was doing great harm to patients and society. She recounts the story of Patrick Tumulty, a late middle age man (and brother of one of her colleagues) with Asperger’s who tried to do the right thing by buying himself coverage on the individual insurance market.
“That is where insurance came in — theoretically” Marcus writes. ‘Unexpected illnesses and accidents happen every day, and the resulting medical bills can be disastrous,’ warned the Web site of Assurant Health, which sold Patrick his policy. Its policy, Assurant promised, “provides the peace of mind and health care access you need at a price you can afford.’ Except it didn’t. Assurant balked at paying Patrick’s claims. In just four weeks, he had racked up more than $14,000 in bills. ‘And that was just to figure out what was wrong with him,” wrote Patrick’s younger sister, now my Post colleague. ‘Actually treating his disease was going to be unimaginably more expensive.”
As I blogged last week, I sympathize with the people whose insurance is getting canceled now because it doesn’t meet the new federal standards. I agree that the President’s promises that people could keep their insurance plans was misleading, something he apologized for today. I understand that some of the people who had an affordable plan on the individual insurance market liked it and didn’t want to see it canceled. A small number of them may have had “good” plans that offered most but not all of the benefits now required by Obamacare—but they were plans offered by insurers who were allowed to pick and choose who they wanted to cover and what benefits they would offer to the exclusion of someone else. And for every one of the “winners” who came out ahead in the pre-Obamacare individual insurance market, there are many, many more who couldn’t get good insurance at any price, or who found that their insurance didn’t really protect them from bankruptcy when they got sick, like Patrick.
I don’t think it is an unduly paternalistic to set safety and consumer protection standards on the sale of products that can have a direct impact on our health and safety—think cars, tobacco, food, motorcycle helmets, and yes, health insurance. All such regulation limits our individual choices to some degree, but only to the extent that they prohibit manufacturers from selling something to us that is harmful, unsafe, and deceptive, all of which describes the products that typically were available in the individual insurance market, albeit with some exceptions, before Obamacare. The goal isn’t to paternalistically second-guess our own choices, but to ensure that the products we can choose from are safe, effective and do what they promise, health insurance included.
Today’s questions: Do you think it is paternalistic for the federal government to set consumer protection and benefit standards for all health insurance sold in the United States? Or necessary and appropriate regulation to end the sale and marketing of health insurance products “ that most people find unacceptable at best, outrageous at worst.”
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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