Two Cheers For ‘Obamacare’

There's an old sad joke in health policy circles: A bigshot policy wonk, who worked his life away trying to get a good universal health coverage plan in place, dies and goes to heaven where, due to his good intentions, is granted an audience with God. “Nice try,” says God. “Any questions?” The health reformer says, “Yes - it's too late for me, but when will America have universal healthcare at last?”

“Not in my lifetime,” God replies.

The Patient Protection and Affordable Care Act, aka the ACA, aka healthcare reform, aka “Obamacare,” is now two years old, and still an infant. As noted by the Public Health Institute, a respected advocate in this arena, this 'infant' has already benefitted of many people thus far:

“Because of the Affordable Care Act:

• 2.5 million young adults under the age of 26 have health insurance because they could stay on their parents' plan.

• 105 million Americans no longer have lifetime dollar limits on their coverage.

• More than 17.6 million children with preexisting conditions can no longer be denied coverage.

• Insurers now must cover a range of evidence-based preventive health services without charging co-pays or deductibles.”

And then there's that contraceptive mandate, favored in practice by something like 99% of American women. Yet as everybody should know by now, the ACA is under severe attack, with one result being historic Supreme Court hearings just concluded. As the New York Times noted, it's “open season from all sides.” The AVA printed an attack from the “left” (for lack of a better term) by Dave Lindorff, pointing out that the health insurance industry remains central and profitable under the ACA; the San Francisco Chronicle, recently offered an op-ed by the local “Pacific Research Institute.” The PRI's “research” has no credibility in qualified health policy circles -- it doesn't even register. It's easy to see why they favor the status quo, for as one online comment nicely put it:

Bear in mind that the Pacific Research Institute is an industry front group that used to shill for the tobacco companies and is now doing the same for the insurance, energy, and pharmaceutical industries. Funding comes from PhRMA, Pfizer, Lilly, and various right wing sources, including the Schaife family and (surprise!) both the Koch Brothers. Not mentioned in the article: health insurance companies skim 15 to 20 cents of each healthcare dollar before anything is paid to actual healthcare providers.

Well said; groups like the American Enterprise Institute, the Competitive Enterprise Institute, the Cato Institute, the PRI, and many others, like the tobacco industry-funded “Tobacco Institute” years ago, are just modern corporate twists on the world's oldest profession. As noted in the Los Angeles Times, “ critics of the overhaul have outspent supporters by about three-to-one on advertising related to the reform law in the two years since the law was enacted; 410 advertisers have spent $204 million to air 1,018 advertisements critical of the health reform law, while 48 advertisers have spent $58 million on 90 positive ads.” Thus, it's hardly surprising that support for the ACA has stagnated over the two years since adoption.

Nobel prize-winning economist and New York Times columnist Paul Krugman, after reviewing what is really known about the ACA thus far, concluded “what's a virulent opponent of reform to do? The answer is, make stuff up.” That seems to be the norm from the right, if one reads the Wall Street Journal and other similar diatribes. And their approach works, as many of the Tea Party-susceptible citizens parrot all sorts of illusions about “socialism” and other specters. “Death panels” were one such bogeyman; “Keep government out of my Medicare” is perhaps the classic political statement of our time. But the real death panels are in the actuarial tables of the health insurance industry.

From the opposite political angle, the ACA is seen as a sellout that did not go nearly far enough to provide access, especially when the “public option” was gutted from the reform package. Lindorff hopes the Supremes will reject the whole thing, thus setting the nation on a healthcare meltdown path that will result in a real revolution, with healthcare for all. He proposes that expanding Medicare would accomplish that in the most efficient and economical manner. I agree with him; but I also wish The Beatles would reunite. Alas, it ain't gonna happen, maybe not in my lifetime. And as Krugman notes, in this regard, “The perfect is the enemy of the good.” Holding out for “Medicare for All” is a good future goal - and contrary to Lindorff's conspiracy-minded charge that nobody will publish arguments in favor of this approach, it has appeared for years in leading health policy journals, in letters to editors nationwide, and just this week, in Robert Reich's weekly policy column in the Chronicle. But in the meantime, we have the ACA, a step in the right direction, overall.

Recently, veteran health policy guru Stuart Altman, a health official under Nixon, Reagan, Clinton, Bush #1, and Obama, recently spoke at the University of California, San Francisco medical center about the history of efforts to improve health access and quality in America. He knows this field firsthand and his new book Power, Politics, and Universal Healthcare is a good retelling of a “century-long battle.” It's also a reality check for those who attack “Obamacare” (a pejorative term that has drifted into the mainstream) as either socialist or sellout.

Three primary impediments to real reform are that (1) most Americans have access to care, and feel mostly fine about it; surveys tend to show that we like our doctors, our hospitals and so forth, but just don't trust or like the systems or professions as a whole. But we don't want our own access changed, and thus the fears of systemic change. (2) The dominant “fee for service” setup whereby providers are paid is too expensive, but any real attempt to change that has been killed over the years. Options such as Kaiser are set up and do fine, but FFS remains the norm. (3) Lots of people in the healthcare system do just fine the way it is, and thus, real reform remains a no-no.

The ACA is not evil. True, it was (unavoidably) hashed out via lobbying and politics and could have been a lot better, and probably simpler. And I think anybody knowledgeable must admit that there are some serious unknowns regarding the eventual impact of the ACA. One serious concern is how all the millions of newly-covered people will “access” care given that we have a large and growing shortage of primary care physicians (something the “market” for specialties continues to make worse). For most of us, the main message regarding current reform at this point is still “wait and see.” The reforms contained in the ACA are really just underway, with some positive patient benefits and protections already implemented, and much more coming. Much of this was going to have to occur anyway -- and still will, regardless of how the Supreme Court rules on the mandate for coverage and other aspects of the ACA. Having heard high-level consultants telling hospitals, doctors, and health systems how to survive and even prosper with the new reforms, I can say that many people are working very hard at making this work for everybody. It's setting up a more competitive field, based on both quality and cost, such has not existed before. There will be winners and loser, as always.

One big question, the biggest for many, is that it's far too soon to know if all this will translate into cost savings -- but compared to the status quo projections, that is very possible. But that might require some other tough medicine, including reducing a lot of waste, improving how we deal with end-of-life care, cutting administrative costs, and taxing the external costs of health-damaging products like alcohol, tobacco, and sugar. In any event, if somebody tells you the ACA has had all sorts of negative impacts already, they are jiving -- that's too soon to know, too. Yes, health care providers, businesses, and insurers are confused about the new rules and regulations rolling out -- but that was already true, and things like rate controls on insurers seem to be popular with just about everybody other than the insurers themselves (and, again, their front groups).

We pay more than any other nation for worse outcomes overall. And many people suffer for that. So any reform must be measured against the status quo, not some pipe dream of a “free market” -- which has never existed in healthcare anyway. It was much worse before Medicare and Medicaid were started in 1965. The “good old days” weren't. And while Medicare is more efficient, equitable, and favored than virtually any other approach, expanding it would require taxation that is not politically feasible in this political realm, and changes in payment that scare many but will be essential before too many years. That is, if Paul Ryan and his Republican cronies don't gut it altogether first.

Some of the Supreme Court justices tipped their hand last week with specious speculations about forcing people to buy broccoli and so forth. The could well kill the ACA, and if so, as Reich notes, the health insurers will “swarm Capitol Hill” to remove requirements that they cover preexisting conditions, and that then Obama should demand Medicare for all. A nice scenario; maybe The Beatles could play at that bill signing too. Don't hold your breath.

Distinguished professors such as Stuart Altman tend to be circumspect about their feelings, and choose their words carefully, even blandly. But here's what Altman told us in San Francisco about the “PR wars” regarding the ACA: “When I read and hear all the accusations of this current attempt at reform being 'socialism' or a 'government takeover,' I can't help but be a little sick to my stomach,” he said. “Those of us who have worked and lived with these issues for decades just wonder “What are they talking about?' This is an incremental attempt; it's not a revolution, it's just evolution.”

But of course, we know how some people nowadays are even opposed to that.