Thursday, January 19, 2012

Politicians won’t admit it, but repeal means taking real benefits away from real people

Politicians who favor repeal of the ACA like to talk in general terms about getting rid of the two thousand pages of law (“monstrosity” is their preferred description) that it created, ignoring the fact that those same pieces of paper extend or improve benefits for hundreds of millions. It is easier to make rhetorical points about “government-run” health care than to explain what you are willing to take away, and from whom, or what you would offer to replace it.

The reason for this, I think, is mainly political: if the politicians really leveled with the people about what they and their families will lose if the ACA is taken away—and without a realistic alternative—many voters would think twice about repeal.

Consider this. Imagine that it is a week from now, and Mitt Romney is in St. Petersburg, Florida, campaigning to wrap up the GOP nomination. Imagine if he gave the following speech to a group of mostly senior citizens:

“Dear friends. As you know, I am opposed to ObamaCare. I am opposed to government-run health care, and my first item of business when I am President will be to repeal it. But you have a right to know what this might mean for you.

Say you are a senior citizen who is receiving a 50% discount on brand-name drugs filled through Medicare’s donut hole—I see there are quite a few of you in the room! After repeal, the discount will disappear. So if you are now paying $100 a month for a prescription, you will pay $200 monthly after ObamaCare is repealed. This means that after repeal, a typical senior enrolled in traditional Medicare will pay $3500 more for their drugs over the next decade.

Also, if you are a senior on Medicare, you now get routine preventive exams, like screening tests for cancer and an annual wellness exam at no cost to you. But after repeal, you will have to pay out of your own pocket for the deductible and co-payments. Yes, the 1,348,087 Florida seniors who now get these services for free will have to start paying for them.

Your internist will get paid less to take care of you. Right now, primary care doctors get a 10 percent Medicare bonus on their office and nursing home visits. After repeal, they won’t get the bonus. What this means is that a typical internist will end up being paid $8000 less from Medicare after repeal. Also, starting in 2013, primary care doctors were supposed to get a big raise from Medicaid, so that the program would pay no less than Medicare. In Florida, this would have meant that Medicaid payments to your primary care doctor would have gone up about 45 percent. But after repeal, Florida Medicaid will go back to paying primary care doctors only a little over half of what Medicare pays them.

Some of you may have granddaughters and grandsons who just graduated from college—congratulations!—and are out looking for a job. In the past, they probably would have lost their health insurance after graduation and until they got employed. Not now, though: the health reform law allows them to be covered under their parents’ plans—some 2.5 million young adults nationwide in 2011 got health insurance as a result. But after repeal, their parents’ plans no longer will have to offer them coverage, and they probably will have to find an affordable plan on their own, if they can.

Some of you may have a grandchild with a pre-existing condition, like asthma. Today, insurance companies can’t turn them away. After repeal, though, nothing will stop an insurance company from turning away or dropping kids who are unfortunate enough to be sick and need health insurance.

Right now, insurance companies must spend at least 80 percent of the premiums they collect from working people on patient care, not profit and administration. After repeal, there are no limits on how much they would be allowed to take out of premiums to pay their CEOs eight-figure salaries and hand out big profits to their shareholders.

Finally, starting in 2014, most of the nearly 4 million people in Florida who don’t have health insurance will get coverage, either through Medicaid or a private health insurance plan that the government will help pay for. After repeal, most of them likely will still be without coverage.

These are the facts, folks. I want to be honest with you, repeal means taking real benefits away from real people. But I favor repeal, because I don’t think the federal government should be involved in your health care. I don’t think we can afford it. I don’t think people should be required to buy health insurance. I don’t think we should tell insurance companies how to run their businesses. And if you need help from the government, I think you should ask Governor Rick Scott for help, because the states can always do it better than the federal government, right? Don’t you agree?”

Mr. Romney saw that the room was strangely silent, many in the audience seemed visibly upset, and few even had their calculators out. Funny, he thought to himself, the polls say that a majority of Americans favor the ACA’s repeal. I guess they weren’t really ready for straight talk about what is really in the law and what they could lose. Next time, I think, I will stick to the tried-and-true railing about government-run health care, and leave out the details about what benefits the voters will lose. They can always find that out after I get ObamaCare repealed.

Obviously, no politician in his right mind would give a speech like this. And I understand that Republicans like Mr. Romney have strong philosophical and pragmatic reasons for opposing the Affordable Care Act, notwithstanding the benefits that it offers to millions. I also understand that President Obama and the Democrats aren’t leveling either with the American people on the fact that Medicare and Medicaid can’t be sustained as they currently exist, and that pretending otherwise and demagoguing solutions does a disservice to the public. But I do think the public has a right to know that “repeal ObamaCare” means that they and their families will get less in benefits and pay more for their health care, and if the politicians won’t tell them, then someone else must.

Today’s question: Do you think politicians who favor repeal should level with the American people about the benefits they will lose if the law goes away?


DocByron said...

Politicians should always acknowlege the negative effects of their proposals. Esp with health care. If they want to repeal the ACA I want ti hear their Plan B.

Robert J. Sobel, M.D. said...

I guess we have to rehash this issue, as the political rhetoric is taking over again. The Supreme Court will have their say and the political landscape will shift this November one way or another. While you acknowledge the democrats may not be leveling with us, I am not sure your defense of Romney makes much sense (how strong can his philosophical concerns be in light of his Massachussetts experience?). As well, tonight, Mr. Gingrich won South Carolina and he is one of strong feelings on health care whose script tends to stray far and wide. Furthermore, the chosen examples in your imagined speech could certainly be debated more effectively (the drug rebates manipulate out of pocket in the right direction but leave the part D fiasco untouched; the wellness exam is entirely irrelevant, as all Medicare patients could see Medicare participating doctors for visits providing these services before ACA; the Medicaid system remains chaotic and litigation is rampant on multiple levels currently; primary care physicians will need more than the 10% bonus to survive as independent entities involved in the care of Medicare patients [especially if it comes with more administrative mandates that distract from the actual care]; the 80% MLR may end up working the wrong way, as it still leaves room for excessive profiteering and creates a cat and mouse between the government and insurances). I could go on, but I think you know there are plenty of examples that could be highlighted and debated.

The recent CBO brief reiterates the limited benefits to disease management, care coordination, and value-based payment to date, as gleaned from demonstration projects. The Ohio take on medical homes will be another example to follow. I know your point of view here, and I'll reiterate my point that a shortage of bureaucracies is not the right diagnosis for our ills.

My hope is that we weather this year with a tenable and wise decision from the Supreme Court and a political landscape post election where a streamlined ACA II is created. The President has admitted that this is a first step and it is true that the history of health insurance is a complicated tale of back and forth accommodation (Paul Starr is as astute as anyone on tracking this history and remains an insightful voice we should heed moving forward). Financing smartly the new technologies and commodities of medicine will get us much further than reforming an already restrained fee-for-service environment.

Arvind said...

Absolutely. They should level with the people and be clear that that if they don't repeal it, the country will be bankrupt before the next generation can enter the workforce. They should do exactly what the Democrats and President Obama did not do before passing an insane law in the middle of the night.

ryanjo said...

A clearheaded Congress would keep the logical and popular measures and repeal or defund the multiple new government agencies and other "bureau-crap" that makes up the other 999 pages of the ACA. But clearheaded & Congress are antonyms.

I am surprised, however, that the ACP leadership is not yet disabused about their "good enough for now" and "seat at the table" attitude, given the present lack of progress about payment reform, paperwork reduction and everything else that bears heavily on the membership's ability to practice the profession.

Harrison said...

"I could go on, but I think you know there are plenty of examples that could be highlighted and debated."

I lifted this from Dr. Sobel's post.
I would ask that he do so.
Mr. Doherty has enumerated clearly the benefits over and over.
All I here from the other side is some vague threat about not being able to afford it.
This suggests that if we don't enact the ACA then the costs won't exist. The ACA does very little to the federal budget and even less to the dollars that come out of the pockets of Americans for health care.
It does offer a mechanism in it to start addressing those problems, which also is belittled.
But it is belittled with no alternative suggested.

Please enumerate concerns.
Please along with them suggest alternatives.
And cite some evidence or logical thought processes as to how it would work.

The most evidence based and logical arguments against the ACA that I have read really come from the left. The single payer crowd has great arguments and evidence in real life.
But I am in agreement that this is politically unfeasible, and I think it is undesirable for American society and culture.

Gov Romney is hypocritical because he knows the ACA can work, because he enacted it in MA and it did work.
Speaker Gingrich is hypocritical on so many levels it is hard to list them all. But on this issue it is mostly because he was in favor of a mandate for insurance coverage before he was against it.
President Obama is not hypocritical, although he did run against Sec. Clinton by saying the mandate wasn't necessary and then agreed when the bill got to legislation form that it was necessary. So he too pushes the hypocritical envelope.

Mr. Doherty makes fact based statements.
He presents great arguments.
And the main argument against him is something like: 'stop saying that I don't want to hear it.'


Robert J. Sobel, M.D. said...


I am not a politician. The repetition of some of the talking points is something we have been doing for a few years. There is a discourse out there. As well, I am not telling Mr. Doherty what to write. Just responding to his well posed questions.

ACA table of contents

No limits or prohibitions (already on record in favor)

Dependent coverage (the initial move to 26)

Preventive service coverage (brings up big issues; complex in era of high deductibles and HSA's, in general though, definitions create arbitary layers of rules)

Ensuring quality is a section I can re-review but scares me in several ways.

Administrative Simplification does not address my daily complaints.

A whole section on regulating insurance industry, not my domain but will be manipulated to ensure 20-25 % of the pie. When they are hassled, I will be hassled.

The creation of the new bureaucracy the exchange. My patients in the insurance industry seem hassled by this whole process.

Employer responsibilities. Our role in providing health insurance was already closely regulated. More layers on small guys furthers the consilidation trends.

The Medicaid expansion and rule changes

Quality measures in Medicare despite lack of proof of benefit

Payment accuracy- we shall see

Limit Part C- fine with me

Addresses Part D- more appeals and improvements in coverage while not addressing drug costs. A glaring omission

Increasing allied professionals

Funding education on geriatrics, culture competency, nurse education grants

Sunshine Act stuff fine with me, but realize the external forces that manipulate practicing physicians are not being targeted (i.e., the extreme costs of new drugs and technologies)

Staff training

Patient-Centered Outcomes Research

Revenue provisions through tax of high cost insurance, tax further unsused HSA and Archer MSA accounts, more requirements for charitable hospitals, annual fee on branded drug manufacturers (this is my after the fact tax; they then raise prices further to offset), annual fee on device manufacturers, annual fee on health insurance providers (who pays that?), limitation on excessive remuneration paid by certain health insurance providers (another cat and mouse)

So there you have it, a quick run down of the table of contents.

We might as well wait for the Supreme Court to decide on the little bit that is the mandate and the Medicaid/states issues.

The saying that it is a lot harder to rescind a law than pass a law should be considered. Harrison, thank you for the challenge.

Harrison said...

Dr. Sobel. I appreciate the list of concerns. It is very thoughtful.
But many of the concerns you list you indicate that you are fine with.
Most you simply state without stating whether they bother you or not.
And then the ones that bother you seem to be bothersome because of speculation and extrapolation beyond what is in the law.

I agree that it is anyone's guess what the Supreme Court will do with this.
There was a Supreme Court case near the beginning of the 1900's called the Lochner case. It was one of many rulings that were similar, and it basically held the right of contract over everything else in law.
The case was an objection to a New York state law that limited the number of hours a baker could work. If bakers refused to work 12 hour days, with no days off and no overtime, they basically could not find work. New York put in limits on hours worked and employers objected.
The Supreme Court ruled that bakers were equal negotiators with their employers and could choose to work the hours or not, and the state did not have the right to infringe on that.
It was an awful decision. Most consider it the Court's third worst decision behind Plessy v Ferguson, and the Dred Scott rulings. (Bush v Gore is probably in competition however).

The Court's consideration of the mandate philosophically may see the court return to rulings similar to Lochner. Does the Congress have the right to impose the state's interest on matters of contract at the individual level? Should the state act to make the two sides in a contract (in this case the insurance companies and the insured) more equal?
Lochner was over turned basically in 1937 by FDR's court.
The current court may not side with the court that sided with the Social Security Act.

It is an interesting debate.

And fun to speculate.

I took off on a tangent.

Perhaps I'll try again later.

Take care

Harrison said...

The Worst Case
How health care reform really could get repealed—and why the repercussions would go well beyond health care.

Jonathan Cohn
January 19, 2011 | 12:00 am

After I wrote the post about the Lochner case i decided to do a google search to see if anyone else saw this as a possible rationale.
And this article came up from The New Republic.
The author writes coherently and well, which I didn't.
I would recommend it to anyone who is wondering what the Supreme Court will be thinking about when they decide the case about the constitutionality of the mandate.
It is not at all an over reach by Congress.
It fits in line with many Congressional actions over the last 70 years.
To find it unconstitutional would mean reaching back to arguments that have not held sway in the Supreme Court since before the FDR Presidency.
It is reasonable.
The Court may choose this path.
But...., what would such a decision mean for us as a country and as a fair minded society?

And another consideration is whether this Supreme Court is going to take the attitude of one of the respected judges in one of the Courts of Appeals that considered this case. That judge wrote in his opinion that the political process should not ask the Courts to decide yet another issue that properly belongs in the legislative realm.

And legislatively, it is a done decision.


The Unseen Patient said...

There are two parts to the ACA that have not been well articulated. Dr Doherty has susictly outlines the first by listing the increased costs to those who would benefit from the ACA should it be repealed in toto.
The story of the ACA that also needs to be told is what it is like to live in America without health insurance and without the means to enter our health system.

One more thing. Although we live in a union of 50 states, our lives extend across state lines and we are all citizens of one country. Assuring that all citizens have equal access to health care, makes the country stronger, increases our work force by maintaining the health or everyone, and treats all citizens the same.

There may have been a time that healthcare varied from state to state, but it no longer does. Therefore if having access to care for everyone is value that the Obama administration holds, it will only be possible if this is a federal program.

Keep in mind that care for those without health insurance is already paid for either by the city, county, state or federal government. It is paid as emergency care, disability, loss of working people, social organizations and others.

R Freidin