Monday, March 26, 2012

What now for health reform?

Today, the American College of Physicians, the nation's second largest physician membership organization and largest specialty society, reminded the public why it is essential that the country not turn its back on reforms to provide all Americans with access to affordable health coverage. The statement, issued the day that the Supreme Court will begin to hear oral arguments about the Affordable Care Act's constitutionality and three days after the second anniversary of it being signed into law, points to the millions of Americans who already have been helped by the law. These include: young adults who are now on their parents' plans, children who can't be turned down because they have a pre-existing condition, seniors who have access to no-cost preventive services and reduced prices on prescription drugs, and fourth year medical students who are getting loan forgiveness or scholarships to practice primary care in underserved areas.

But the biggest changes are yet to come: affordable health insurance for nearly all Americans and 32 million fewer uninsured, to be achieved by offering sliding scale subsidies to help people with incomes up to 400 percent of the poverty level buy competitive private insurance offered through state-run exchanges, expanding Medicaid to pay for the poorest families (paid for almost entirely by the federal government—100 percent in 2014, going down to 90 percent of the cost by 2020—so that it isn't an unfunded mandate on the states), and a ban on insurance companies turning down or overcharging anyone who has a pre-existing condition. Oh, and the requirement that people pay a small (but unenforceable) penalty—the law doesn't allow the government to file charges or liens against people who refuse to pay—if they can afford health insurance but refuse to buy it.

These changes are hardly radical, and they are not "socialized medicine." (Only in the weird world of American partisan politics could subsidizing someone to buy for-profit private insurance be called socialism.)

And they used to have bipartisan support. ACP first proposed a similar set of policies in 2002 with no objections from our more conservative members—in fact, the only objections I recall came from liberal doctors who favored a single payer system! ACP's ideas were then incorporated into a bipartisan bill, the HealthCARE Act, introduced in two consecutive Congresses. Conservative think tanks including the Heritage Foundation until recently advocated a similar set of policies, including the individual insurance requirement that it now says is unconstitutional. 

It was only when these policies became the Affordable Care Act, or "Obamacare," that bipartisan consensus broke down. 

Now, the question is: will the Supreme Court, and the U.S. political process, allow these reforms to remain, or will we go back to the days when the country tolerated 50 million or more uninsured persons and allowed insurance companies to cherry-pick who they choose to insure? 

I don't know what the Supreme Court will rule, and ACP's statement stayed away from the constitutional arguments because the organization's expertise is in evidence-based development of health policy, not constitutional law. But based on its assessment of the most effective ways to expand access to health care, ACP concluded that the key reforms created by the ACA—subsidies, exchanges, Medicaid expansion, and the individual insurance requirement—should be maintained.  

I see no other viable political pathway to achieve ACP's decades-long vision that every American, no matter where they live or work or how rich or poor they are, should have access to affordable coverage for essential health benefits. If the ACA goes, there will not be a "replacement" plan offered by the law's opponents that will come anywhere close to providing coverage to nearly all Americans. (The GOP plans offered to date—health savings accounts, buying insurance across state lines, and medical liability reforms—would not materially reduce the percentage of uninsured Americans, according to the Congressional Budget Office.)

People will disagree on whether universal health insurance coverage is a right, but there didn't use to be much disagreement that it is the right thing to do. As we hear arguments over the next few days about the Commerce Clause, states’ rights, the anti-injunction act, broccoli, and rationing, I hope we don't forget the millions who have been helped by the ACA, and the millions more who will be if it is allowed to stand.


ryanjo said...

This post is a classic "straw man" argument: "It's kind of a good concept, so let's just swallow a little sugar-coated poison. Only some of us will die!"

The good components in this bill could have been put into effect without legislative action for the most part.

The objectionable parts:
-- such voodoo economics that even the CBO flip-flops repeatedly
-- untried experiments such as ACOs and pay-for-performance coercion for doctors
-- providing universal coverage without any pilot programs that could uncover huge costs and likely frauds that will develop
-- let's have mandates on paper, but the fines are unenforceable and so low that it will falter fiscally
-- it makes sense for employers to simply drop employee coverage, dumping millions into new & untried programs
-- multiple new administrative bodies sucking budget dollars
-- a payment board with near-invulnerability for its determinations
-- the same broken delivery of care that has almost bankrupted us already
-- all the big stakeholders go home with full pockets, with docs and patients like fish in a barrel.

Let's not pretend the Supreme Court action will change anything. It is just the first and easiest step in a long period of turmoil that will unravel this ridiculous law. Hopefully those of us who actually do the work won't be throttled before it's all played out.

Steve Lucas said...

Of interest may be the March 20, 2012 Wall Street Journal piece ObamaCare's Flawed Economic Foundations by former CBO director Douglas Holtz-Eakin and Nobel economist Vernon L. Smith.

Steve Lucas

Arvind said...

Please stop spreading false messages, Bob. This law neither provides patient protection nor is it affordable to the country.

doc777 said...

How's that "all in" policy working out for you Bob? Even the liberal justices are tearing Verrilli to pieces.

The November election and the GOP sweep will finally render the ACP irrelevant. The ACP leadership just does not get it. It's time for plan B. Oh wait, there is no plan B. So sad to see this organization implode. We had a real opportunity to advocate for the proven cost-effectiveness of Internal Medicine and the E & M services we provide, but instead the leadership got on the Medicaid-for-all train. Great job. Give each other a pat on the back.