Thursday, August 7, 2014

“Obamacare” is a lifeline, not a train wreck

For years, critics of Obamacare (Affordable Care Act), have predicted that it would turn out to be a “train wreck”—or something worse.  But now we know that by every objective measure, the ACA is working out pretty darn well.  Let’s run through the “train wreck” predictions, and what we now know to actually be the case:

Train wreck prediction #1:

“Obamacare will lead to skyrocketing health care cost increases and explode the deficit.”

Typical was the claim by Obamacare opponent Avik Roy that “healthcare spending will explode under Obamacare.”

But now we know that:

In 2012, total health care spending increased by 3.7%, the “lowest rate since 1960.” Most recently, the CBO substantially reduced its forecast of projected deficit spending, largely because of the slowdown in healthcare spending.  And the CBO’s director confirmed his agency’s long-standing view that the ACA will lower the deficit.

The ACA may not be totally responsible for the healthcare spending slow down—the same thing is happening in other wealthier countries reports the New York Times.

But the facts to date show that Obamacare surely has not caused health care cost increases to skyrocket, or the deficit to explode; rather, health care spending has slowed and deficits are going down.

Train wreck prediction #2:

“More people will lose coverage under Obamacare than gain it.”

Speaker of the House John Boehner was one of many ACA critics who made this claim.

But now we know that:

Far more people gained coverage than lost it.

The Washington Post’s independent fact-checker wrote in March that there’s “more than enough to demonstrate that no matter how you count it, there has been no net loss in insurance coverage.”

In fact, today we now know for sure that Obamacare has allowed far more previously uninsured people to gain health insurance coverage than lose it.  It’s not even close.  Kaiser Health News reports that three independent studies found that the ACA “reduced the number of uninsured adults by 8 to 11 million people”.  Politico, a highly respected, independent and non-partisan news source for DC policy wonks and politicians, concludes that “by now, the trend is unmistakable: Millions of people who didn’t have health insurance before the Affordable Care Act have gained it since last fall. The law is not just covering people who already had health coverage, but adding new people to the ranks of the insured — which was the point of the law all along.”

To recap, these are the plain and simple facts:

Opponents of Obamacare predicted that Obamacare would become a “train wreck” because health care spending would skyrocket and the deficit would explode as a result.  The fact is you’d have to go back over half a century to find a time when health care spending has  grown so slowly;  the CBO says that federal deficit spending is declining (largely due to the slowdown in healthcare spending), and that the ACA will continue to lower the deficit in the future.

Opponents of Obamacare predicted that it would become a “train wreck” because  millions more would lose coverage than gain it.  But the fact is that under Obamacare, the uninsured rate is the lowest it’s been since at least 2008, according to Gallup, with the rate dropping across nearly every subgroup—extending coverage to some 8 to 11 million previously uninsured adults.

For the millions who have gained coverage, Obamacare today is looking a lot more like a lifeline than a train wreck.

But it’s not only the uninsured who benefit.  Don’t we all share in the benefit of having  lower healthcare spending, lower deficits, and from seeing fewer of our neighbors delay getting needed health care because they couldn't afford health insurance?

Today’s questions:  Is Obamacare a train wreck or a lifeline?  And if you still think it is (or will become) a train wreck, what facts do you have to back that up?


ryanjo said...

Economic journalist Robert Kuttner calls feel-good posts like this about the ACA, "whistling past the graveyard".

The 2012 "lowest rate since 1960" increase in total health spending
-- occurred well before the (botched) rollout of the exchanges in November 2013 (so no claims paid). And 27% of signups were age 18-34, although this group is 40% of the eligible. So the covered group is older and will use more benefits
-- occurred before the individual subsidies needed to be paid out
-- the recession limited the ability of consumers to purchase healthcare
-- deductibles and copays rose 50% or more in the 5 years before 2012, resulting in less consumption of healthcare services
-- Obama kicked the can down the road by grandfathering many inexpensive policies that would be canceled by the ACA

So 8-11 million uninsured gained coverage?
-- if you call a policy with a 5-8 thousand dollar deductible "health insurance"
-- if you can find a doctor in the narrow panel policies incentivized by Obamacare

Mis-attributed statistics and Executive Office shenanigans has (so far) dressed up the train wreck into the party train.

Just keep whistling.

Harrison said...


I again don't get what it is you are for.

You want the market to help us with health care, right?
So we now have more out of pocket costs, and the result is quite predictably that there is less spending and with that, health care inflation slows.
It doesn't recede. It just falls to a rate a little closer to the rest of inflation.

Isn't that kind of what you want?
I'm mean, the market that is?

And with doctors choosing to not be part of the panels that included patients who previously couldn't afford insurance, well,...isn't that what you wanted too?

I mean, well, I guess I saw your vision to be one of a market.
And in that market doctors get to choose patients as much as patients get to choose doctors.
And people would pick doctors and care options based on their budget.
And they would buy insurance products that they can, and the doctors would choose to be part of the panels, or not.
And maybe patients could see doctors not on the panels and perhaps submit for reimbursement, but pay the doctor, but then the insurance could point to some small print line that says they don't have to pay.....
But we would stick with fee for service no matter what.
But hopefully we would lose the link between insurance and employment....

I'm sorry but I'm lost.

What is it you want?

You know, don't you, that without Medicare and without insurance, doctors would go bankrupt all across the country.
ER's would be excessively busy, even more than now.
People would die, unnecessarily.
Patient safety would be a pipe dream.
Drug companies would suffer.
Our health care system and probably a large part of our economy would collapse.

So can we not start from a basic agreement that Medicare and Insurance are here to stay?

The alternatives that are realistic are either Obamacare, or some version of it that looks an awful lot like it,
or a single payer system with the health insurance industry being essentially taken over by the federal government.
Medicare for all.

We can agree that the scenario where the government completely pulls out of health care is unrealistic, right?

So is Bob whistling past the graveyard?
I don't know.
But who cares.
What alternative are you envisioning that makes this criticism worthwhile?


ryanjo said...

Being realistic is what brought us to our present state of affairs. I'd rather call it lowered expectations. Or maybe Stockholm Syndrome. When a victim comes to believe the same values as the aggressor, he no longer feels helpless or threatened.

Obamacare is about the furthest from a market-driven approach that can be envisioned. It subsidizes the same sick healthcare system with more taxpayer money. But doesn't free "providers" to deal directly with consumers without both sides being controlled by third parties. Prices are set, services are required or proscribed, payments are arbitrarily reduced or increased depending on budget sequestration, meaningful use and loss ratios -- initiatives of our beneficent government which still struggle to prove relevance to quality patient care.

You don't "get it" because for years the profession has surrendered so much economic and professional autonomy to third parties, that patients & doctors can't imagine dealing one-on-one with each other. As a doctor, pay me what I charge, or go elsewhere. As a patient, I'll choose my doctor on qualifications, professionalism and cost. That's how a market works, not whether the doc is in-network, Par or Non-Par. If the government or insurers want to help patients pay, so be it, but don't threaten me with loss of my license, or the patient with non-payment of their benefits unless their doctor has signed on the line.

Oh yes, an individual doctor can go off the grid even now. But since the payment system is controlled by insurers and government, and you are now required by law to pay for insurance, his prospective patients take a double hit. That's not a business model for success.

Again, my prediction is that Obamacare will grind slowly into deficit & underfunding, with gradual cheapening of the profession by diluted services and gaming of the system. And we docs will end up as another public/private utility like the power company. And we all know how long it takes to get them out for a repair. But all the stats will indicate nirvana has been attained.

Yes, I agree that without some help from major organizations (psst, Bob, that means you), we'll all be working for the Man one day. At least then, I'll know who my boss is.

Jay Larson MD said...

Obamacare is doing what it was designed to do. Help uninsured people get insurance. Once insured they will probably access the healthcare system, but this can be a good thing. I have seen a number of new patients who just got their insurance for the first time and as a result got their diabetes or hypertension diagnosed and treated, preventing complications down the road. A far as healthcare spending, this is a large complicated issue that the law does not address well. Our system is still too expensive....over $80,000 for one round of treatment for hepatitis C with the new drugs. There is still a lot of people profiting handsomely from the health care system and until that can be reigned in, costs will still be an issue.

Harrison said...

ryanjo said:
"Oh yes, an individual doctor can go off the grid even now. But since the payment system is controlled by insurers and government, and you are now required by law to pay for insurance, his prospective patients take a double hit. That's not a business model for success."

I couldn't agree more.
This is truly a problem. It harms any doctor who doesn't want to be part of a panel, and it harms any patient who wants to seek care outside of a standard approach.

I don't know how to fix it.
But I just wanted to be sure to point out something that I wholeheartedly agree with ryanjo about.

Diversity of choices in healthcare is a good thing.
It is important to preserve it.
Obamacare is definitely a step away from that.

I can make an opposing argument about the statistics for the health of the public good being better served by a standard approach and by set standards, and Obamacare improves that.

But it is at the cost of a loss of diversity of choices.


PCP said...


When you say:
I couldn't agree more. This is truly a problem. It harms any doctor who doesn't want to be part of a panel, and it harms any patient who wants to seek care outside of a standard approach.

Can't you see that this is by design and not an accident.
For example, the sliver of patient and primary care doctor freedom ie HSAs were severely curtailed and capped (washington language for killed off slowly by inflationary forces). Same as fee for service with the SGR etc etc.

And yet with this as the background the ACP and AMA gave it a full throated endorsement. That is my point exactly, we were sold out and that is why I have boycotted membership of these organizations.
We as a profession have been put in a cage and are now being dictated to by those in control of our professional lives. Sadly that is translating into erosion of our professional independence( putting it in the hands of bureaucrats and administrators) and impeding our ability to deliver best quality care. It will lead to pre determined salary caps via global budgets that in the future will further erode our livelihood. You had better be planning for this because it is on the way, rest assured. These are not theoretical possibilities, they are our future on the current trajectory which seems set.
And this law through various mechanisms, one of which you have just acknowledged, but there are others in there, makes that absolute control of the profession the law. And it is through us that they control patients, I resent myself (a doctor) being put in that position as well.
It is precisely the reluctance of organized medicine to safeguard those freedoms for Doctors and patients alike that I find so disgusting.
I hope you are beginning to see the light. This law will be a horrible thing for me as a patient in 20 yrs.
I too am for access to care, I for 7 yrs while I tried my had at private practice took indigent call for my community hospital and based on circumstances would care for indigent patients in follow up even when they could not pay if I felt I could help them. However this law annihilates small practices, and removes any hope of survival for cash pay practices. It is really bad for all concerned.