Tuesday, January 3, 2012

Beyond repeal, what would the GOP do about health care? And Obama about entitlements?

Hard to tell . . . and maybe not much, judging from what the presidential candidates have put forward so far. Last Friday—just in time for the first votes taking place today in the Republican nominating process—the American College of Physicians posted a comparison of how the major candidates propose to deal with health care access, workforce capacity, and costs of care. There isn’t much for a voter to go on.

The Republican candidates uniformly say that they want to repeal “ObamaCare” but aren’t saying much beyond that, which is too bad. The 2012 election may very well determine the ACA’s immediate political future—will the law stay or go? President Obama, of course, favors continued implementation of the law, the Republicans want to it to go away. But what else do we really know about the candidates’ plans?

If the Supreme Court overturns the individual insurance mandate, the Republican candidates will applaud the decision, but what do they propose should replace it? Will they also want to get rid of the popular prohibition against insurance companies discriminating against people with pre-existing conditions? If not, how would they make the pre-existing condition provisions work without the mandate? When they say they favor the ACA’s repeal, does this meant they want to repeal some of the ACA’s other popular provisions, like discounts on prescription drugs offered through Medicare, and coverage of preventive services at no cost to the patient? Or do they want to repeal only parts of the ACA, and if so, which ones?

If the ACA is repealed, what will they do about the 51 million who lack health insurance, and the 30 million who would get coverage under the ACA? Do they think it is okay for millions of Americans to go without health insurance? Do they have a plan to cover them? Or have some other way to ensure that they have access to needed care?

What will they do about rising health care costs, the number one contributor to the federal budget crisis? A mainstay of GOP criticism of the ACA is that it doesn’t do enough to control costs, but at the same time, the candidates are critical of the programs in the ACA that are supposed to help lower costs and have been vague about their own cost control plans. Would they repeal the ACA’s funding for comparative effectiveness research? For designing and implementing new payment and delivery models like Accountable Care Organizations? If IPAB goes, how would they save the same amount of money? What are their alternatives to lower health care costs?

What about the growing shortage of primary care physicians, expected to reach more than 40,000 by the end of the decade? Would they repeal or cut off funding for the programs in the ACA that are supposed to help, like increased funding for the National Health Service Corps, the redistribution of unused residency slots to primary care, and grants for primary care training, education and practice improvement? If they feel the market will solve the primary care shortage problem, how—since the market has consistently undervalued primary care?

Speaking of free markets, would the GOP candidates break up insurance company dominance of certain markets? Lift price controls on doctors and hospitals? Go after drug company practices that limit competition and drive up costs?

Hard to tell . . . and maybe not much, because the GOP candidates aren’t saying.

What have the GOP candidates proposed, other than getting rid of the ACA? Most seem to agree on selling insurance across state lines, enrolling more people in health savings accounts, giving states more options, and reforming the medical liability system, but that’s about it. Such reforms, though, would only insure about 3 million more people and have only a nominal impact on cost, according to the Congressional Budget Office. And we already know that many states, left to their own devices, have done an abysmally poor job in providing access to poorer residents.

Now, on most of these issues, it is easier to tell where President Obama stands—like it or loath it, his Affordable Care Act lays out a specific set of policies that the president has pledged to uphold. But he won’t say what should be done if the Supreme Court overturns the individual insurance mandate later this year.

And on entitlement reform, the Republicans have been far more specific on their plans than President Obama: most of them would convert Medicare to a defined contribution program and Medicaid to block grants. President Obama has been critical of both, but unclear on what he would do to reduce the growing costs of both. Increase the retirement age to 67, or make higher income people pay more? Offer a voucher system along with traditional Medicare?

Hard to tell . . . and maybe not much, because President Obama isn’t saying.

ACP believes that physicians have a professional responsibility to be informed advocates for patients, but the candidates have a responsibility to inform the public on what they would do if elected to the country’s highest office. Being against the health reform law isn’t enough—the GOP candidates need to tell us where they would take us. Being against Medicare vouchers and block grants isn’t enough—President Obama needs to tell us where he would take us on entitlement reforms. If they don’t, and they end up in (or in the case of Obama, return to) the Oval Office, they hardly will have a mandate to make the difficult decisions needed to ensure access, control costs, and have enough doctors to take care of patients.

Today’s questions: Do you think the presidential candidates are saying enough about what they would do about health care? What do you think about ACP’s comparison tool?


Harrison said...

The comparison chart seems to be characterized by a lot of: "the candidate has not made a proposal relative to this issue."
And the positions they do stake out do not break new ground. Block grants and Health Savings Accounts. None of which solve either the problem of access or costs.

The only candidate that does address these issues is President Obama.
Of course his positions can be poked at, but they are backed by some evidence and they are forward thinking suggestions relative to the problems that confront us.

Rep Paul would have us really step backwards. He seemingly would advocate the dissolution of Medicaid and Medicare along with the ACA. And also he would take down the FDA. And cap malpractice awards.

I can see where that may seem like something worth fighting for.
An unregulated medical market with prices set by physicians.

But really.
Are we prepared for the implications of that?
No access for the elderly with chronic problems.
More use of ER's as a rescue, with those using it not having any ability to pay.

I'm not sure.


ryanjo said...

I don't feel the same way about Obama's positions. The kindest thing that can be said is that his ideas are uninformed and untried. More pertinently, his plans are to dump the responsibility to reform healthcare on physicians, along with paying us less and making us restructure our practices along the lines that government bureaucratic wonks think make sense. His White House staff has published an article that we will all be soon working for big corporations (really helped drug costs and professionalism now that most pharmacists work for the chains, didn't it?) He's the first president to dishonor our profession by announcing to the public that we do tonsillectomies to make money from frequent sore throats.

He is just the same as all the other politicians, bad ideas, which he has already begun to recant to massage his poll numbers. The only longterm solution is the government completely out. And the solution for this year -- all the incumbents out.