The ACP Advocate Blog

by Bob Doherty

Tuesday, July 10, 2012

The uninsured aren't the issue???

For most of the past 100 years, there has been a bipartisan consensus that enacting legislation to ensure that every American has access to health insurance is a national priority, even as Republican and Democrats disagreed on how to get there. The Washington Post’s Ezra Klein notes that as recently as 2007 Senator Jim DeMint (R-SC), now a Tea Party favorite, sent a letter to then-President George W. Bush offering to work with him to pass legislation that would “ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage.”

Senator DeMint could have been channeling President Teddy Roosevelt, who first called for universal coverage in 1912. Teddy, of course, was a Republican.

Much has changed in five years. Earlier this week, Senate Minority Leader Mitch McConnell was asked by Fox News how the GOP planned to address the more than 30 million uninsured who will lose access to health insurance if the Affordable Care Act is repealed, and he replied “that is not the issue.” His position is now the mainstream consensus among most Republicans—enacting legislation to provide coverage to all Americans is no longer the party’s objective. None of the “replace” plans offered so far by the GOP—selling insurance across state lines, health savings accounts, or medical liability reform—do much of anything to reduce the number of uninsured. 

Which is too bad. The country could surely use a spirited debate between the parties on how to make sure Americans have health insurance coverage they can afford. We know that the GOP hates Obamacare and will do everything it can to make it go away. But I wish it would offer an alternative that shows us how they would cover everyone that costs less, doesn't raise taxes, uses free market principles, and has a smaller role for government, if such a thing is possible, instead of saying that the uninsured are not the issue. In other words, do what the 2007 version of Jim DeMint advocated, and develop a plan to “ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs.” This would be a debate worth having in this election year.

And in my mind, and in ACP's view, the uninsured ARE the issue. Today, the Annals of Internal Medicine published a commentary from me, asking whether the Affordable Care Act, as changed by the Supreme Court, is a milestone or detour on the road to universal coverage. My answer is that it is both: it will expand coverage to tens of millions, but the Supreme Court's decision on the Medicaid provision opens up the possibility that in some states, coverage would be available to everyone except the poor. I don't know how anyone could reasonably justify making an explicit policy decision to shut out the poorest among us from coverage. Yet that's what the Supreme Court decision allows, and what some states, regrettably, are threatening to do.

My Annals article quotes Dr. Atul Gawandes's observation that “[M]any levers of obstruction remain; many hands will be reaching for them. For all that, the Court's ruling keeps alive the prospect that our society will expand its circle of moral concern to include the millions who now lack insurance. Beneath the intricacies of the Affordable Care Act lies a simple truth. We are all born frail and mortal—and, in the course of our lives, we all need health care. Americans are on our way to recognizing this.”

I hope he is right, and that Republicans and Democrats alike will once again agree that the uninsured are the issue, and that our society must expand its circle of moral concern to include the millions who now lack health insurance. And then debate how best to get them insured, instead of saying that this isn't the issue.

Today's question: Do you agree or disagree that the uninsured aren't the issue?

13 Comments :

Blogger Jay Larson MD said...

Yes and no. Our health system is twice as expensive as any other country with relatively little emphasis on primary and wellness care. Having more people insured will reduce the number of bankruptcies in this country, but it won’t fix the cost issue. As it has been said…”Affordable” quality health insurance. Even with Government subsidies, access to primary and wellness care will be an issue if reimbursements are too low for office visits. Our country has got to stop paying top dollar for hospital care, pharmaceuticals, and procedures. Physicians have to stop ordering the newest, most expensive technology which has not been proven to be any better than the less expensive older technology. I just read an article in Archives of Internal Medicine about the frequent use of drug eluting cardiac stents when a bare metal stent could suffice…saving this country $400 million if stents were used appropriately. Yes it is about the uninsured (our health care system can easily bankrupt a person), but it should also be about the cost and how to use our health care dollars more wisely.

July 10, 2012 at 2:38 PM  
Blogger ryanjo said...

As we critics of the ACA in its present form have stated in these posts, the goal of providing health insurance to as many Americans as possible is not contested. But the devil is in the details...

As Jay Larson has said above, is it enough to merely extend our old broken system to millions more? To establish new & untried bureaucracies to add more overhead to providers? To deprive those who now have employer provided insurance with taxes and increasing cost of policies (yes, average premiums have increased over 40% since ACA has passed).

The ACA is a political bill, and always has been. It rewards the drug companies & insurance cartels, gives waivers to big companies & unions, puts billions in new Supreme Court approved taxes on working people, our mortgages and a dozen other ways. Physicians had better jump on the corporate bus or be run over (our ACP will show you how). My thanks to the supporters of the ACA for their lesson on morality. I guess political philandering of this type doesn't constitute immorality.

Billions spent on "economic recovery" have been wasted. So now lets pledge billions more on an untried system that our President and his party thinks will work. Our President whose health care knowhow consists of stating pediatricians (?) remove kids tonsils after an earache to pad their pockets (Mitch McConnell has no exclusive on "foot-in-mouth" statements). I guess that explains IPAB -- he needs to discipline us.

I suspect the "levers of obstruction" are really just Dr. Gawandes admitting that "you can't fool all the people all the time", as a much wiser President said.

July 12, 2012 at 10:01 PM  
Blogger Arvind said...

I couldn't have said it better than ryanjo.

And can you please explain why I should accept 40% of my billed amount as fair compensation and use part of that payment to insure the same patient that I am treating?

This would not make sense for any other professional, so why should it make sense for doctors? Oh, I forgot, we are the "noble profession". But I don't see it remaining a profession any more; the ACA has successfully converted it into a job and our service into a commodity!

July 14, 2012 at 11:28 PM  
Blogger Steve Lucas said...

Carrying on with Jay and ryanjo”s thoughts, I was surprised with the announcement Friday that waivers were going to be allowed in the welfare to work programs. This program, originate by Bill Clinton, has done more to control welfare cost and improve the standard of living of Americans than any other single program.

The medical result will be maintaining a higher Medicaid role as people are not encouraged to move into the work force. Yes they will have insurance, but can they find a doctor to provide care?

I am also confused by the reduction in the amount allowed in a health savings account and the increase in the amount needed to be allowed to deduct medical expenses. This will impact those with high deductable policies, who are usually individuals, or those working for small companies, who do not have access to a corporate sponsored policy.

I would think these actions would limit a person’s access to medical care due to reimbursement or lack of funds.

Steve Lucas

July 15, 2012 at 11:39 AM  
Blogger Harrison said...

Oh my.
It is a social problem in America that we have many people uninsured or underinsured or under tremendous debt because of medical care.
The cost of health care is an economic burden for the country on many levels. It weighs down our federal government. It makes our businesses uncompetitive.
These are two separate but major social problems, and they are both frequently dealt with together. When someone proposes something to help with one issue, many criticize it because it doesn't address the other.
The Affordable Care Act was clearly aimed first and foremost at the problem of the uninsured. In order to garner enough votes in Congress and enough support from the industries involved it was weighed down and watered down with clauses that aim at cost containment and at cost shifting.
One of its biggest problems from a public perception standpoint was that it was phased in over 4 years.
The Massachusetts plan was phased in over one year. It was attacked for one year, but survived and then became popular once enacted.
The ACA has been similarly attacked but with much more force and for a much longer time, and the main parts of it have yet to be enacted.

I'm not sure how to react to all of the posts that are here in response.
There is a lot of hyperbole and not a lot of substantiated claims or complaints.

President Obama didn't author the bill. He championed it but I'm quite sure he would be the first to admit he doesn't know how health care is delivered. So it isn't really a surprise when he says something nonsensical as an example.
He doesn't know how to run a car manufacturing company either, but when he channeled money to GM it worked out okay.
He didn't author that either.

If we want cardiologists around the country to use bare metal stents when they are appropriate then I think we need to have a federal agency with some knowledge and evidence and teeth to be able to do that.
And there should be a healthy debate about what they are enforcing, and if the evidence is only mediocre then it should be left to individual cardiologists and their patients entirely.
Even with teeth in the regulation, the individual cardiologists should be able to make a case for actions needed in individual cases, and they should be given the benefit of the doubt often given the circumstances under which they often are forced to make decisions.

Or we can structure their payment in such a way as to encourage them to keep up with current evidence.

In primary care we are already facing that frequently. I lose money for over use of specialists on capitated patients.
I lose money if I have too few patients appropriately using preventive services appropriately.
I lose money on capitated patients if I have them visit too infrequently (with numbers that are kind of arbitrary and not evidence based0, etc...

Health care is moving away from fee for service reimbursement.
We don't know if it works or not but we know for sure that fee for service with a deep pocket third party payer leads to over use of services.
And rapidly escalating health care inflation which is unsustainable.

That is unfortunately all I really hear from the side of the argument that wants to repeal the ACA; the notion that we should simply continue with fee for service medicine.
That is not going to happen.
Repeal the ACA or not, we are not going to move backwards towards more fee for service.
We will likely move forward into capitation schemes no matter what.

Sorry.

Private or public funding is kind of a side show.
The real change that will effect us is what we do that earns us money for our practice models on a day to day basis -- and that will be less based on fee for service whether it is from private or public sources.

And with the economy we have now, we can expect more of our patients to be falling under public sources of money, or simply coming to the ER with no ability to pay at all -- and bankrupting more and more hospitals.

HLR

July 18, 2012 at 6:55 PM  
Blogger Harrison said...

As for welfare to work????
What?
The administration is offering to allow states that are strapped for money to find ways to use the remaining state employees working on behalf of welfare recipients more freedom from paperwork and more time with their clients.
What exactly is wrong with that, other than the fact that it is a coming from the Obama administration and John Boehner wasn't asked to put it to a vote with Obama's name attached so that it could be publicly defeated by the Tea Party?

And also, please provide some proof that Welfare to Work programs have helped. Helped who?

HLR

July 18, 2012 at 6:55 PM  
Blogger Steve Lucas said...

Harrison,

The 1996 law passed by Bill Clinton was called PRWORA. This law included many provisions that were intended to eliminate the then generational nature of welfare. One aspect of the law that applied, regardless of income, was new child support regulations expanding and standardizing child support payments and enforcement.

The current issue is TANF, a part of that original statute. During the time this law has been in effect no President has chosen to unilaterally change this law. You can read the concerns of one of the law’s authors at this link:

http://m.yahoo.com/w/legobpengine/news/administration-proposes-welfare-waivers-184813543.html?orig_host_hdr=news.yahoo.com&.intl=US&.lang=en-US

I do not have an exact number of the people this law has helped. What I do know is that the current law has helped many move from welfare into paying jobs, with, we hope private insurance. My attorney wife spent her entire career working in child support and saw first hand the positive results of this statute, and remembers the welfare queens she dealt with starting out.

My personal belief is that helping, typically women, out of welfare and into a job is a program with merit. The changes proposed seem to be more than just the paperwork required.

Steve Lucas

July 19, 2012 at 12:12 PM  
Blogger Harrison said...

Steve,

This is from the article you sent as a link:

In its memo to the states, the administration said no waivers will be allowed that could reduce access to employment, nor will they permit exceptions to time limits on welfare assistance. Waivers can be revoked if the experiments don't work out. Still, a state can seek a waiver to cover its entire welfare population.

"We will hold states accountable," said George Sheldon, head of the federal Administration for Children and Families, the HHS agency that oversees the program. "If states are not meeting their performance targets, their authority to test new ideas will be terminated."

And nothing else you said suggests any level of support for the statements whatsoever.

So I stick with my bewilderment.
Why is anyone to believe that this grievance is anything more than a partisan attack?

By the way, there was only one President between Pres Clinton and Pres Obama, and that was Pres Bush and it is not surprising that he would not have considered any change to the Welfare to Work program.

Harrison

July 19, 2012 at 4:17 PM  
Blogger ryanjo said...

Hyperbole? For one thing, President Obama (if he can stay in office), will be appointing members of the IPAB, which will directly impact physician payments. It doesn't concern you that he can't articulate the difference between a pediatrician and ENT surgeon? Or that he considers that our motivations are as pecuniary as his own profession? I call that naive. Whether he helped author the ACA or just supports it out of ignorance is equally frightening.

As far as unsubstantiated statements:
-- "Healthcare is a burden on our country many levels"...prove that statement! Healthcare is one of the few segments adding jobs. Healthcare entities are posting record profits (unfortunately, not doctors). Look over the balance sheets and stock prices of the major hospital corporations, big Pharma, health insurers, health tech companies -- and then compare them to GM, Microsoft & HP. I submit that mismanaged government entitlements are the burden you speak of, and ACA is just the latest boondoggle.

-- "when he channeled money to GM it worked out okay"... GM hit its lowest U.S. market share in decades earlier this year, and last quarter lost over 250 million dollars on overseas sales. Ford (which declined Obama money) and Toyota (which "only" had an earthquake to deal with), both gained market share on GM. Backing a losing venture seems to a theme of this administration.

I do agree that healthcare is moving physicians away from paying them for services rendered. The ACA is first and foremost about "bending the cost curve", by all and any means, proven or not. Capitation is not quality, and the HMO experience of past years shows that the top 5% of IQs in this country (MDs) can easily defeat such a simplistic system.

Prediction (based on experience, no proof claimed): ACA will be both a catastrophic economic failure and huge embarrassment by the end of the next President's term, whoever that may be.

July 20, 2012 at 9:28 PM  
Blogger Mt Doc said...

The article is about the uninsured, the 50 million of us (many times the population of my state) who either cannot get insurance due to preexisting conditions, cannot afford it because they don't make enough for the 12-15 grand cost and their employer does not provide it, or who decide to forego it and play the lottery that they won't need it. Other than a universal single payor system, it is hard to see how these people could be covered without mandating that insurance companies cover those with preexisting disease, require everyone to enter the insurance pool to make the above economically possible, and give assistance to the middle group above. I would really like to hear ryanjo's proposed solution to the above problem.

The health care system may not be a burden to those of us making a living form it, myself included, but it surely is for the 50 million uninsured, those who have gone bankrupt or been financially devastated by medical bills, employers who have to cover enormous insurance premiums for their employees, and anyone unfortunate enough to get a chronic disease requiring expensive treatment. Checked the price of one dose of remicade lately?

July 23, 2012 at 11:24 AM  
Blogger Mt Doc said...

The article is about the uninsured, the 50 million of us (many times the population of my state) who either cannot get insurance due to preexisting conditions, cannot afford it because they don't make enough for the 12-15 grand cost and their employer does not provide it, or who decide to forego it and play the lottery that they won't need it. Other than a universal single payor system, it is hard to see how these people could be covered without mandating that insurance companies cover those with preexisting disease, require everyone to enter the insurance pool to make the above economically possible, and give assistance to the middle group above. I would really like to hear ryanjo's proposed solution to the above problem.

The health care system may not be a burden to those of us making a living form it, myself included, but it surely is for the 50 million uninsured, those who have gone bankrupt or been financially devastated by medical bills, employers who have to cover enormous insurance premiums for their employees, and anyone unfortunate enough to get a chronic disease requiring expensive treatment. Checked the price of one dose of remicade lately?

July 23, 2012 at 11:25 AM  
Blogger ryanjo said...

The price of Remicaid is evidence of government-pharma industry collusion, combined with overstating effectiveness and underestimating toxicity. And ACA will do nothing to reduce the price, it will just extend the same bad practices to millions more people.

It is interesting to me that the most frequent defense of the ACA by its supporters, when specific criticisms are leveled, is a challenge to supply a better plan. And when the response is simply to allow the market for health care to exist unencumbered by government price controls (overpaying for the lavish & ineffective, underpaying for the basic), the ACA folks claim that "the health care sector is different". Are there fewer hungry people, or poorly housed people, or under-educated people, or people without big screen TVs in America than underinsured? Why don't we have a special government program for these problems? Simply speaking, because we don't know how to fix these inequities, but we do know that social experiments that redistribute wealth generally fail, sometimes in a big way.

July 24, 2012 at 12:38 PM  
Blogger Bridget Hall said...

I think even the online pharmacy reviews are saying (though indirectly, maybe) that the uninsured are the issue in any healthcare discussion, since they're not covered by such benefits in the first place.

January 10, 2013 at 10:23 AM  

Post a Comment

Subscribe to Post Comments [Atom]

<< Home

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.

Share/Subscribe

Bookmark and Share

The ACP Advocate Blog

Recognition

The 2009 Medical Blog Awards
Voted Best Health Policy/Ethics Blog 2009

Healthcare Bloggers
10 Healthcare Bloggers We're Thankful For

Blog log

Health Blog
The Wall Street Journal's blog on health and the business of health.

Health Affairs Magazine Blog
The Policy Journal of the Health Sphere.

The Health Care Blog
Everything you always wanted to know about the Health Care system. But were afraid to ask.

MD Whistleblower
Vignettes and commentaries on the medical profession.

The New Health Dialogue Blog
From the New America Foundation.

Kevin MD
Medical Weblog

DB's Medical Rants
Contemplating medicine and the health care system

EGMN Notes From The Road
Bloggers post from medical meetings, press conferences, and policy gatherings from the U.S. and around the world, providing readers with a tasty analysis of the buzz, the people, and the stories that don't get told.

FutureDocs Blog
A blog dedicated to medical education, news, and policy as well as career advising.

Disease Management Care Blog
An ongoing resource for information, insights, peer-review literature and musings from the world of disease management, the medical home, the chronic care model, the patient centered medical home, informatics, pay for performance, primary care, chronic illness and health insurance.

Medical Professionalism Blog
The Medical Professionalism Blog was created by the ABIM Foundation to stimulate conversation and highlight best practices related to professionalism in medicine.

Powered by Blogger

Comment policy & copyright info