Thursday, January 23, 2014

The Confusing Conservative Critique of Obamacare

Conservatives could muster a clear-thinking critique of Obamacare if they wished, and maybe even put forward a genuine alternative.  Unfortunately, though, many of the conservative attacks on Obamacare don’t make much sense, when evaluated against conservative’s own heretofore views, not against liberal concepts of good policy.

Let’s breakdown conservatives’ confusing arguments against Obamacare that don’t jibe with their previous positions:

1. Conservatives used to be for high deductible plans, until they were against them, when it comes to Obamacare, that is. Bloomberg News points out that Republicans in the early 1990s advocated for high deductible plans as an alternative to the more generous benefits proposed by President Clinton:

 “As Democrats pushed for universal health care during the Clinton years, Republicans argued that consumers should pay a greater share of their medical bills. In 1996 the GOP-controlled Congress passed legislation allowing some people to pair high-deductible plans—which barely existed—with tax-free health savings accounts. That meant that small business owners and their employees, as well as others with limited insurance options, could put away pretax earnings to pay for routine care and buy cheap insurance to cover catastrophes. In 2003 Congress, still under GOP control, passed legislation making health accounts more widely available.”

Today, Republicans are in a lather about Obamacare’s high deductible plans, exposing what policy wonk Ezra Klein deems “their hypocrisy”   over Obamacare (his words, not mine—I think inconsistency is a fairer description).  Aaron Carroll, a professor of pediatrics at the Indiana School of Medicine, opines in Bloomberg that conservatives newfound dislike of high deductible plans brings them to the right (correct) position:

“The revelation that many plans in the Patient Protection and Affordable Care Act’s health insurance exchanges have high deductibles, has put many of the law’s conservative opponents into a corner: Once in favor of high deductibles, these critics of Obamacare are suddenly worried about the risk to consumers. The data show why their new position makes more sense.”

2. Conservatives used to be in favor of moving people out of employer-based coverage but now bemoan every employer who drops coverage because of Obamacare.  Typical is an anti-Obamacare screed from the Republican Senate Policy Committee, warning that people “relying on employers to cover employees’ spouses on the company health plan may find the health care law isn’t ‘working fine’ for them. The law’s mandates and fees are driving up health care costs and making it harder for employers to continue offering health insurance to workers’ families. Some employers have even stopped offering spousal coverage altogether.”  Avik Roy, a conservative physician commentator and former Romney advisor, has predicted that Obamacare will result in employers “cancelling” policies for 80 million employees (which, by the way, has been disproven by independent fact-checkers—his estimate is way too high, and the policies aren’t actually being cancelled, just changed to meet Obamacare’s requirements, such as the requirement that young adults be eligible for coverage under their parents’ plans).

But even if it were true that some employers eventually will decide no longer to provide health insurance in favor of allowing their employees to buy individual (and subsidized coverage) from the competing health plan offered through Obamacare’s exchanges, delinking health insurance from employment used to be what conservatives favored (and some still do).  For example, the libertarian Cato Institute supports elimination of the tax deductibility for employer-sponsored insurance—a far more radical and disruptive approach to ending employer-based insurance than any drop in employer-based coverage from Obamacare:

“In any case, with the removal of the subsidy for health care above catastrophic coverage, the incentive to obtain so much insurance would diminish. Thus, many people would reduce coverage to that level. Insurance companies could help individuals with catastrophic risk management—their traditional function. Firms could get out of the business of managing, rationing, and buying health care. We would delink insurance from employment, ending the portability problem and dramatically reducing the brouhaha over pre-existing conditions. Individuals would have better incentives and more control. More broadly, we need to move away from third-party payment and toward two-party transactions in health care.”

3. Conservatives invented the idea that individuals should be required to buy health insurance but now vociferously oppose Obamacare’s individual mandate. Forbes magazine recounts conservatives’ “torturous” shift on the individual mandate, from originally favoring it as a market-based, personal responsibility alternative to compulsory government-mandated coverage (single payer) or employer-mandated coverage, to now decrying it  as socialism:

“. . . Some conservatives, seeking a more market-oriented path to universal coverage, began endorsing an individual mandate over an employer mandate. An individual mandate would address the ‘free rider’ problem caused by EMTALA, by requiring people to buy their own insurance. In addition, moving to a more individual-based system from the employer-based one would significantly increase the efficiency of the health-insurance market.

With these considerations in mind, in 1989, Stuart Butler of the Heritage Foundation proposed a plan he called ‘Assuring Affordable Health Care for All Americans.’ Stuart’s plan included a provision to ‘mandate all households to obtain adequate insurance,’ which he framed explicitly as a way to address the ‘free rider’ problem and employer mandates.”

To be fair, there is plenty of inconsistency among liberals, and people often change their minds, for good or at least justifiable reasons in their own minds.  But the fact is that until Obamacare, the conservative alternative to government-run health insurance was to provide tax incentives for people to enroll in high deductible plans, to delink coverage from employment, and to require that people to buy coverage.  Yet they oppose these elements when associated with Obamacare. 

This is a problem, because this country needs to have a spirited debate about today’s conservative alternative to Obamacare, one that would limit government and promote free markets yet still expand access to millions of uninsured.  But conservatives need to first figure out what they are for, not just what they are against, which apparently is anything having to do with Obamacare, even if similar to the things they used to be for.  Do they still favor high deductible plans?  Do they still want to delink coverage from employment?  If they no longer support an individual insurance mandate, what alternative do they have in mind to make sure that risk is spread among the young and healthy and the old and sick?  We need to know.

Finally, before readers of this blog accuse me of only going after the conservative response to Obamacare, stay tuned.  My next post will be about liberals’ blind-eyes to the unintended adverse consequences of Obamacare.

Today’s questions: Do you agree that conservative critiques of Obamacare are confusing and inconsistent with their past views?  And if so, is this a good or bad thing?


southern doc said...

You're kind of obsessed with Obamacare. Would it be possible to change the subject every now and then?

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

Fair points and I agree with you that the inconsistency expressed in the politics of the moment is not very useful. I have previously said we will still need effective reform regardless of how we structure the third party payors. I personally believe state-based, not-for-profit, insurance companies would be one aspect, with public programs to a minimum.

I remain most concerned about the bureaucratic creations that are now talking points from just about everyone. Throwing out fee-for-service in the name of cost saving is a farce.

As long as drugs include prices that add up to 10 physician-years of service or more, there is no way that efficiency is being optimized and value added. I started when the pie was $ 1 trillion, and I have seen it grow to 2 and then 3. I can tell you that fee for service physician fees (especially in cognitive fields) are not the driving force of this growth. You have shown data supporting this over the years. Bread and butter medicine is not typically over-doing it. That is the danger of consumer driven cost controls, as people can end up skimping on essential care like blood pressure and diabetes and cholesterol management due to out of pocket costs.

As we see a tacit, if not explicit, insult of modern physicians by saying the incentive to work (oops, I mean do more and cheat) is the ultimate problem in American health care; it is clear that there is some disingenuous propaganda going on.

Create a bureaucracy to measure my quality. Tell me good versus bad. I've seen its face over these last few years, and it is a dangerous big brother bureaucratic tangle that will lead to more harm than good.

Support of bread and butter medicine with proration of the cost of new technologies and fair market value for established pharmaceutical and adjunctive testing is the structure we need. Not all these untested experiments in behavior modification.

Bill Gate just said on Charlie Rose how it is inenvitable that we will have to adjust Obamacare. How could it not be so with so many experimental components being implemented at once. I do agree with this. The voice of the Democrats, Republicans, and our physician organizations, that is a different story. I cannot support the somewhat dreamy rhetoric on how we are going to save the ship with a return to risk management and capitation strategies. Quality will inevitably suffer in a top-down, bottom-line blinded, battle of the big health care behemoths.

Let's fix the real perversions in health care, not fair fee for service.

AVINASH said...

As usual you are missing the real cost of healthcare rise , Instead of talking about politics , why don't you talk about solutions , none of which are there in current system . There is no protection for physicians , there is no cook book medicine approach nor any other elements that could cut the cost .

Harrison said...

At some point I wonder if physicians are going to recognize that our incomes have gone up a lot as compared to the population.

When I started practicing in 1993 there were no hospitalist positions.
General interists were being hired for starting guaranteed salaries of $80K to $120K.

Now outpt internists are expecting to get $190K, or more.
Hospitalists for Kaiser in San Diego County make close to or in excess of $300K.
And San Diego underpays in comparison to much of the rest of the country.

That represents a huge percentage increase in salaries over my career.

That money doesn't come from nowhere.
Insurance companies compete to sign on doctors, and groups want doctors because doctors generate orders which support the local health care economy.

So, the salaries we make are the tip of the iceberg.

We can't really expect to have the cost issues in medicine addressed without seeing pain to physician salaries can we?


W. Bond said...


Using your own numbers (whatever their merit): When you adjust for inflation over 21 years (2.4%) 120K becomes 200K. Confusing nominal dollars with real is sometimes referred to as "the money illusion."

Cheers, wbond

Harrison said...


I think we've done better than keep pace with inflation.
But even if that's all we've done, how many teachers can say the same?
Construction workers?

Even Members of Congress?

They are long overdue for a pay raise.

And it is no comfort that most of them don't need it.
That just means we are being governed by the elite.
How is that a good thing?


PCP said...


Add to the above, the work schedule of a day as an Internist in 1992 and one today. I dare say it is a lot more harried now. One can argue needlessly as we are forced to push numbers to preserve our practices. I am sure you realize the demands on our time are far more intense.
Layer on that the decrease in autonomy and increase in regulatory burden for private practitioners, clunky EMRs, etc. and perhaps your guilt is misplaced eh?
Any meaningful reform to health care dollars must engage patients in their costs of care, must empower physicians to make decisions, and must address the unfettered power of various lobbies that push goods and services at exorbitant prices in congress.
Cutting physician incomes will have the opposite effect eg. General IM Primary care through the 1998-2008 decade when it went through its death spiral, all while you and the ACP felt it all appropriate with your liberal guilt. Hospitalist medicine ironically may have provoked some change in OP medicine by helping creating the void and acute shortage needed to bring the issue to the fore.
Yet we still see ACP endorsed policies, such as Nurse Practitioner autonomy coming to the fore as with recent efforts by the VA to push that profession not as invaluable members of the team, but as autonomous practitioners across the entire VA system. As usual penny wise and pound foolish. This as usual will continue to drive the demand for Hospitalists and other specialists and hence their wages. It won't do a thing about cutting costs, except in the imagination.
General IM is the best value in geriatric primary care, bar none, hands down. It may take a while for the system to come to that realization, but they eventually will. As they say. We like to do everything else and fail before we do the right thing.
Anything other role is a less optimal use of the Internist's time and training, in my view. At any of those wages, you mention, I'd argue we are a steal of a bargain to the system if empowered to do what we do best.

Harrison said...


You wrote "At any of those wages, you mention, I'd argue we are a steal of a bargain to the system if empowered to do what we do best."

I agree.
But I think I've decided to change my goal.
I'm going to look for an employed physician position, and I would love to have you in a management position so I can bargain with you for my salary!



ryanjo said...

PCP is correct. In a 2012 study published in JAMA, the authors state: "From 1996-2000 to 2006-2010, there was no significant growth in adjusted earnings for physicians (−1.6%; 95% CI, −5.4% to 2.2%). Adjusted earnings continued to grow for other health professionals..." (

Unknown said...

I grew up in Italy and I am very familiar with the ills of socialized medicine. My in laws are from England so I can tell many horror stories on the NHS! Unfortunately "Obamacare" aka Affordable Care Act is trying to shift our wonderful medical system into a European one. We may end up as in Europe with a two tier system where the "haves" can afford quality care delivered through private institutions and the "have-not" will have to submit to a bureaucratic system that will deliver rationed, poor, medical care. That is the inevitable consequence of a government run medical care system.

PCP said...

Unknown is wise for he has seen both sides, as have i practiced in both systems.
The uninsured MIGHT GET better chronic care than they are getting now, they will largely get what medicaid patients get today, largely via nurse practitioners and PAs,
Like medicaid, it will turn into another tapeworm on the economic system, all while making liberals feel warms and fuzzy inside. Yet for the average blue collar worker, the average employer provided benefits recipient, and for medicare patients it will be demonstrably a less good system. Sadly, I predict this will eventually drive a lot of elective work overseas as well as it gets overpriced and overtaxed to deal with the costs imposed by Obamacare. All while more nimble, less taxed and less regulated competitors in and around the US, develop their systems. It might yet turn out to be the irony of ironies, that US trained physicians and nurses start practicing south of the border. Now there is an idea for a billionaire entrepreneur.