Thursday, November 29, 2012

"Honest Abe" and ObamaCare

“Passed by corruption, aided and abetted by the purest man in America” is how anti-slavery Congressman Thaddeus Stevens described President Lincoln’s successful effort to enact the 13th amendment, banning slavery.   This historically accurate quote, which runs counter to the public image of “Honest Abe” Lincoln, is among the many  fascinating  stories recounted in the Steven Spielberg’s masterpiece  “Lincoln” playing  now in movie theaters nationwide.  

The movie doesn’t claim to get every fact right, but its description of Lincoln’s single-minded determination to get the 13th amendment passed by Congress in the final months of the Civil War-- over the objections of his own advisors and knowing he initially was at least 20 votes short-- is spot on.  And to get the votes he needed, Lincoln did whatever he thought was necessary, including offering jobs to lame-duck members of Congress who had lost re-election.  (This practice was not illegal at the time, although undoubtedly ethically suspect).   Today, offering jobs for votes would be against the law and grounds for impeachment.
But the movie depicts Lincoln’s commitment to banning slavery in an extraordinarily favorable light.  Human bondage was such a moral wrong, the source of misery for enslaved millions, and the cause of heart-breaking bloodshed for the entire country, that if there ever was a case of the ends justifying the means, this surely was it.

The film depicts “politics as hand-to-hand combat, and it portrays Lincoln not as idealist or moralist but as pragmatist and realist. Doing so does not diminish him but elevates him.”   For his efforts, though, Lincoln was called a tyrant by his critics.

There are lessons from Lincoln that we might keep in mind as we consider our current political divisions.   As much as the fight over taxes and spending cuts seem like a big deal to us, and seemingly outside the reach of compromise in an ideologically polarized Congress, it is not even close to the stakes and divisions Lincoln faced over the 13th amendment.   The movie shows the unseemly side of politics but also shows members of Congress acting in an extraordinarily honorable ways:  voting their consciences, voting against the position of their own (in this case, Democratic) political party, and putting their careers at risk for voting for the amendment.  It shows abolitionist Thaddeus Stevens tempering his rhetoric in favor of full equal rights for African-Americans in order to win votes for the amendment. 

Wouldn’t it be something if there were more members of Congress today who would vote their consciences and buck their parties?  Who would be willing to hold their tongues and compromise when needed to advance long-term priorities?

The lesson we can learn from Lincoln is that politics can be both high-minded and unprincipled.  The process of getting legislators to vote your way always has, and always will, involve some degree of wheeling and dealing. So it was in Lincoln’s time, so it is today.

To be clear, I am not arguing in favor of offering jobs or money for votes, or selling out to the highest bidder, or even bending the rules by flying members of Congress around in corporate jets to elite golf outings.  Those things today are for the most part illegal, and we are better for it. 

But let’s stop looking at politics through Rose Colored glasses.  ObamaCare’s critics got themselves into high dudgeon over the “backroom deals” the Obama administration made to win support from interest groups and individual Senators (The Democrats were equally indigent when House Republicans kept the vote on Medicare prescription drug coverage open for four hours in 2005 to arm-twist the final votes they needed for passage).

The promises made to get interest groups and lawmakers on board with Obamacare (all legal, by the way) don’t come close to the “do what every is necessary” Realpolitik exercised by Lincoln.   But as the National Journal’s Jill Lawrence writes “If Lincoln were operating now, though, Americans would be following all the wheeling, dealing, and good-government lamentations in real time on Twitter and cable TV. I’m guessing there would be plenty of cynicism, and certainly no halo — at least until decades later.”

I am not equating ObamaCare to ending slavery, by the way.  For all of the good that health care reform may do in my opinion, it doesn’t rise to ending slavery.  Nor am I saying that Obama is the measure of Lincoln:  no one today can say how Obama’s presidency will be viewed by historians, and Lincoln sets such a high bar that it unlikely that any contemporary politician will come close.
But I am saying  that sometimes achieving a principled end—like covering the uninsured—requires a certain degree of arm-twisting and deal-making.  Sometimes, the end (within reason) does justify the means.  Jill Lawrence concludes that the film “exalts ends without sugar-coating means, and holds out the promise of vindication — in history, if not their lifetimes — for leaders who wield their ‘immense power’ to perfect the nation as they see it.”   Just take it from Honest Abe.

Today’s question: What lessons do you draw from the account of Lincoln’s deal-making to pass the 13th amendment?

Wednesday, November 21, 2012


In the spirit of tomorrow’s celebration, here is a list of ten things, related to health care, for which I give thanks:

1.     I am thankful that my immediate family and I are in good health, to the best of my knowledge.

2.    I am thankful that when my family members and I get sick, as we all will someday, we have good health insurance and won’t have to worry about being bankrupted because of high health care costs or having to go without care because we can’t afford it.

3.    I am thankful that a little over a year from now, when the Affordable Care Act becomes law, as many as 32 million uninsured Americans, and many millions more of us with pre-existing conditions, will be able to say the same.

4.    II am thankful that I have the privilege of working for an association of internal medicine physicians—the American College of Physicians—that has have shown remarkable prescience, leadership, determination and commitment to advocate for what they believe to be best for patient care, taking on the really tough issues of universal coverage, cost, payment and delivery system reforms.

5.    I am thankful that I was able to play a role in helping ACP develop its policy positions on universal health insurance coverage, the rational allocation of health care resources, and many other challenging issues--and subsequently seeing so many of them accepted into law and regulation.

6.    I am especially thankful for my contributions to getting coverage to nearly all Americans through ACP’s advocacy on behalf of the ACA.

7.    I am thankful to have gotten to know so many physicians through my work that are everything one could ask for from the medical profession: smart, dedicated, and compassionate women and men who spend their days and nights making health care better, by taking care of patients, by teaching the next generation of physicians, and by helping ACA develop and advocate for responsible patient-centered policies.

8.    I am  thankful that I have the opportunity to work with so many other people—my friends colleagues on the ACP staff, the people I know who work for other health advocacy organizations, and the many dedicated and unfairly maligned public servants who work in government—who also have dedicated their careers to improving American health care.

9.    I am thankful that I live in a country where public policy decisions on controversial issues, like the ACA, can be debated freely and with decent respect for each other’s views.

10.    I am thankful for  those of you who put up with my musings In this blog, whether your just read or take the extra time to post comments on it, even and especially when you disagree with me (as I am sure some of you will about my expressions of gratitude for the ACA!). 

I wish each of you a peaceful and restful day of Thanksgiving with your loved ones!
Today’s question: If you made your own list of ten things related to health care for which you would give thanks, what would they be?

Tuesday, November 13, 2012

Rooting for the ACA’s Failure?

Beyond stating what now should be quite obvious—that ObamaCare is here to stay—what does the 2012 election mean for health care reform?  On one hand, the voters have spoken, re-electing a Democratic president who is committed to full implementation of the law over a Republican candidate who promised to repeal it on “Day One”—while expanding Democratic control over the Senate and reducing the Republican majority in the House.   As a result, there is no realistic scenario where there will be the votes in Congress to roll back the law.  Also, exit polling suggests that just one-quarter of voters favor complete repeal of the Affordable Care Act.  On the other hand, it would be a gross misreading of the election to say that voters have enthusiastically embraced ObamaCare.  The same exit polling shows that voters are split nearly down the middle on the law’s future, with slightly more (47%)  being in favor of keeping or expanding it compared to the 45% who said they thought it should be fully or partially repealed.

In other words, complete repeal is off the table, at least for the next four years. But the proponents of ObamaCare haven’t yet won the hearts and minds of a solid majority of voters.  That likely will only happen if the law is successfully implemented at the federal and state levels, and voters find from their own actual experience that it is a good thing.  But if its implementation is messy, confusing, uneven, unsatisfying, and/or too costly, then the public could yet render a judgment against it. 

What worries me is that the ACA’s opponents, having failed in their “three year war against ObamaCare”, will decide that their best remaining option is to do their darndest to make implementation confusing, uneven, unsatisfying, and/or too costly for the public.  Then they can say “we told you so” and hope that the public agrees. 

So, for instance, a large number of conservative states might decide not to set up the  state health exchanges through which federally-subsidized insurance will be sold to qualified residents, hoping that it simply is too much work for the federal government to effectively set the exchanges up and run efficiently for millions of persons in (potentially) dozens of states.  They might decide not to accept federal dollars to expand Medicaid to their poorest residents, as at least a half dozen states are threatening to do, thereby ensuring that implementation will be at best uneven, leaving behind many of the most vulnerable people who were supposed to get coverage under ObamaCare.  Also, under the ACA, hospitals and other safety-net clinics will get fewer federal dollars to offset the costs of treating indigent patients because they were supposed to be fewer of them as Medicaid is expanded.  But if their state doesn’t agree to the expansion, those same safety net institutions still have to treat the indigent patients that will be denied access to Medicaid, but with a lot less funding—potentially forcing them to close or at the very least resulting in cost-shifting to those with insurance.  And then the politicians in those states could say, see, it is all ObamaCare’s fault, even though it was their own opposition to the Medicaid expansion that made the law untenable for their safety net clinics!

And setting up the law to fail in the states that oppose it is precisely the advice being offered by some ObamaCare critics.    Arguing that the federal government can’t “competently operate dozens of exchanges. . . Republican governors should allow the feds to live with the mess they created rather than clean up for them” writes Philip Klein in the Washington Examiner.   And, at the federal level, the House GOP could again try to use its leverage over spending to try to deny the administration the funds it needs to implement the law, although this wasn’t very successful in the outgoing 112th Congress, and will likely be even less so in the new one.

If the critics of ObamaCare decide to do everything they can to undermine its implementation, they are essentially putting patients at risk to make a political point.  States that refuse to set up the exchanges or agree to the Medicaid expansion will be making it harder for their residents to get access to health insurance.  By refusing to lending a hand to the federal government’s effort to make the law work in their states, they may succeed in making it more confusing for the public and less likely to achieve the law’s goal of facilitating enrollment in qualified health plans, but how can it be good public policy to make it harder for people sign up for coverage?

There is a better way, which is to get over the polarized, ideological and hyper-partisan political debate over ObamaCare, accept that it is here to say, to acknowledge that a majority of voters could have elected a President and Senate committed to its repeal but didn’t, and instead seek bipartisan avenues to improve it.  USA Today reports that some Republicans and Democrats are beginning to talk about ways to “come together and fix it” rather than continuing the fight over killing it on one hand or keeping it exactly as is on the other.   History reminds us that this is what happened when Medicare and Medicaid were enacted in 1965: after initially being fiercely opposed by conservatives, and after several election cycles where voters chose the candidates that favored continuing those programs rather than the ones promising to repeal it, the cries for repeal faded, the efforts to disrupt implementation ceased, and repeated Congresses and administrations found a way to enact bipartisan legislation to make them work better. 

Isn't it time for the country to come together to try to make the Affordable Care Act work, including fixing things that are wrong with it, rather than rooting for (and even trying to facilitate) its failure in delivering on the promise of accessible, affordable health insurance for all?

Today’s question: How would you answer the above question?

Wednesday, November 7, 2012

ObamaCare is here to stay

With the re-election of Barack Obama and Democrats retaining control of the Senate, the debate over the future of ObamaCare is over: it is the law, will remain the law, and will be fully implemented in 2014. To the extent that there is still a question about its future, it is whether the states will agree to expanding Medicaid to all of the poor and near poor and to set up marketplaces to buy subsidized private insurance. Every state that says no to either or both will take away from the law's promise of taking of covering nearly all Americans. And the fact remains that the public remains deeply divided about the law. Still . . . there is a chance, a hope, a promise, a potential, that the country can move past the polarized, ideological debate over repealing ObamaCare on one hand (won't happen) to making it better (could happen). The election doesn't settle which choice the country will make, except that it will not be repealed. But I hope that when realization sets in among the public that ObamaCare won't be repeated, there will be a renewed willingness to take what is good about the law, especially coverage of the uninsured, and make changes where needed (how about real medical liability reform as a start?) to make it better Today's question: What do you think the election mean for ObamaCare?

Monday, November 5, 2012

The Election

So it all comes down to this: tomorrow voters will be deciding not only on who they want in the White House and in control of Congress, but also on two fundamentally different views on the role of government in health care.  President Obama proposes to continue to expand the federal government’s role in financing, funding and regulating health care and continue Medicare and Medicaid as defined benefit programs; Governor Romney wants to turn more responsibility over to the states, cut federal healthcare spending, and convert Medicare and Medicaid from defined benefit programs to defined contribution programs, limiting the federal government’s contribution to each.

I expect that most readers of this blog have decided which approach you favor and who you will vote for, based not only on their positions on healthcare but on the economy, national security and other issues that matter to you.   It would be presumptive of me to evaluate the candidates for you and, as a matter of policy, law and good sense, ACP does not endorse candidates for political office.  We have and will always be strictly non-partisan, taking positions on the issues based on ACP policy, not positions on the candidates themselves.

As a resource for those of you who want to learn more about the issues at stake, here are links to content that I hope you will find to be of interest, some from previous posts to this blog, some from the ACP  and Annals website, others from respected advocates, commentators, and journalists:

ACP’s comparison of President Obama’s views compared with College policies

ACP’s comparison of Governor Romney’s views compared with College policies

NEJM article from President Obama on how he “would secure the ACA’s future”

NEJM article from Governor Romney on how he would “replace ObamaCare with real reform”

My article from this week’s ACP Internist publication on how the election may decide four critical health policy issues

Annals perspectives from health policy experts David Blumental, Gail Wilensky and Bob Berenson on what the elections mean for healthcare

Article from the ACP Advocate Newsletter discussing how healthcare was addressed in the presidential debates

Medical Economics magazine article that quotes me, AAFP’s President, and others on how the election might affect primary care

NPR report on the prospects for ACA repeal should Governor Romney be elected

Blog post from the Washington Post’s Ezra Klein on why healthcare is the most important issue in the 2012 elections

My blog post on the ten things that bother doctors the most that are being overlooked by the candidates

Analysis from NPR’s Julie Rovner on how Governor Romney would reform healthcare and how his approach differs from President Obama

My Annals of Internal Medicine article on the Supreme Court, the elections, and the ACA’s future

My recent blog posts on the leadership deficit of both candidates and who is to blame, the secret truth behind Medicare vouchers and their unpredictable risk and benefits, and how the candidates’ positions on Medicare are a triumph of nonsense over substance.

No matter what your views are on the candidate’s and their positions on healthcare, I hope that my blog posts and links to others’ expert analysis have helped inform you about the issues at stake.  And, once the dust settles and we know who won the election, I will post my own post-election thoughts and share insights from other experts, and like always, seek your thoughts as well.

Today’s question: How are the candidates’ views on healthcare influencing your vote?

Friday, November 2, 2012

A Proud SOB’s Perspective on Healthcare and the Election

I am a proud SOB—Son of a Bartender—just like John Boehner (R-OH), the Speaker of the House of Representatives.  We both grew up helping out in our Dads’ working class bars—in my case, I was the third generation to tend bar (summer job while in college) in Doherty’s Bar in Woodside, Queens, NY, owned, operated and tended by my late father Jack Doherty, an Irish immigrant.  Where I respectively disagree with Speaker Boehner is on whether the Affordable Care Act (ObamaCare if you prefer) will help or hurt working class people, like the longshoremen, cops, construction workers and firefighters who patronized my Dad’s establishment.  I believe it will help them and should be fully implemented, Speaker Boehner believes it will hurt them and should be repealed.

I am sure we can both cite statistics and studies to back up our views, yet I think it is important to go beyond the numbers and look at how it specifically will affect real people with real healthcare needs in real jobs, such as those who tend bar or wait tables for a living.   Which brings me to a Missouri bartender I met back in 2009,  before ObamaCare became law, who overheard a conversation between me and Dr. David Fleming, the then-governor of our Missouri chapter and now a member of ACP’s Board of Regents.  This is an excerpt from what I wrote then in this blog:

"I was in Missouri attending the ACP chapter meeting. Over several beers at the hotel bar, Dave Fleming, the ACP Missouri chapter governor, and I were debating whether health care is a right, privilege or societal responsibility. Our bartender overheard our conversation and asked if health care reform would help her and her family.

"She said she has some serious health problems that require expensive medications, which are only partly covered by the health insurance plan offered by her employer. Her company plan also covers her 19 year old dependent daughter with a serious mental health condition. Her husband, an independent contractor who can't find coverage on his own, also relies on his wife's plan for coverage. She said that even with the insurance, her premiums and out-of-pocket health care bills are so high that "I don't know how we'll make it." She was planning to take a day off from work to plead with state Medicaid office to cover her daughter, even though she had already been advised over the phone that her daughter wouldn't qualify.

"Dr. Fleming and I explained that health care reform might make her daughter eligible for Medicaid, because the pending bills would require the program to cover anyone up to 133% of the poverty level (we didn't ask her how much she and her husband earned). We also told her that she might be able to get subsidized coverage through a health exchange, and that insurers wouldn't be allowed to turn down her daughter or charge higher premiums because of her pre-existing mental health condition. She wistfully responded, ‘I hope so’ but sounded unconvinced that the politicians in Washington would do these things for her.

"As the politicians continue to debate the intricacies of such things as excise taxes, budget offsets, health exchanges, subsidies, mandates, and public options, I hope we don't lose sight of this Missouri bartender, and the millions of working American families, who can't afford health care and are looking to Washington for help. None of the bills making their way through Congress are perfect - far from it. But I believe the litmus test of whether the results are worth it is whether our Missouri bartender and her family can get good coverage at a price that they can afford."

Today, three years later, and just four days before the election, I can say that the politicians in Washington did come through for her:  the Affordable Care Act will expand Medicaid to everyone with incomes up to 133% of the FPL, and provide sliding scale subsidies to buy private insurance for people up to 400% of the FPL through state-run health exchanges.  Less certain is whether the politicians in Jefferson City, MO, will come through for her, because they have to agree to the Medicaid expansion and the exchanges.  But if they do, this Missouri bartender, her self-employed husband, and her disabled adult daughter should have guaranteed, affordable health insurance coverage for the rest of their lives.

I can understand why many voters have concerns about the ACA, mainly because they believe it is too expensive and gives too much power to the government.  But as a proud SOB myself, I hope that we keep in mind  that because of ObamaCare,  this Missouri bartender, and so many others like her, will for the first time in their lives no longer have to worry about not having access to affordable health insurance coverage, unless the voters decide otherwise next Tuesday.

Today’s question:   What do you think is at stake in the election for this Missouri bartender, and so many others like her?