Illustration by Tim Cook
Improve, Don’t Eliminate
Ditching Obamacare may adversely affect health without cutting costs
By Dr. Harry L. Gewanter
Many, many years ago, I wrote a research paper that I thought was the best of all possible research papers. After multiple revisions, I proudly handed it in and awaited the compliments from my professor. He returned it the next day, pounds heavier for all the red ink, with the comment “Nice First Draft” emblazoned upon the title page. Once my ego recovered and I went through his many suggestions, it was better.
My view of the Affordable Care Act (aka Obamacare) parallels that experience. The underlying framework and premises are good, but can be improved with some revisions.
The core goals of providing essential health care to the most Americans while minimizing or eliminating many of the loopholes in health insurance policies were accomplished, albeit incompletely. Removing the prejudicial penalties for preexisting conditions and addressing the lack of coverage for habilitation services that help patients learn or improve skills are but two examples of improvements to the pre-ACA health insurance landscape. Additional enhancements could include elimination of the Independent Payment Advisory Board, increasing transparency while minimizing administrative burdens for pre-authorizations and appeals, and capping out-of-pocket costs.
The hyperbolic, emotional and ideological statements, both positive and negative, about the ACA are neither completely true nor false. What is true is that more Americans have been able to obtain health care services since its inception and that the rate of rise in health care spending has slowed. All prices for health insurance, both on the exchanges and through employers, have increased and most Americans are paying more for their insurance, regardless of how or where they purchase it.
All legislation is a compromise between ideals and realities, and the ACA is no exception. These compromises blunt both the potential positive and negative effects of the legislation while providing adequate fodder for criticism on all sides.
I am concerned that the overly polarized positioning by all sides will result in diminishing the overall health of the nation without any cost savings. I can’t think of many people who were ecstatic about their pre-ACA health insurance benefits or costs, and I fear a return to those times. Health care costs were the leading cause of bankruptcy before the ACA. Many of the proposed plans to replace it, such as high-risk pools, have failed in the past to provide adequate care or were prohibitively expensive for many Americans.
I am concerned that data showing beneficial effects of the ACA will be ignored on an ideological basis and that evidence-based decision making will not be used by those creating the environment in which patients and constituents live. We all pay for each other’s health care, be it directly or indirectly, in both dollars and lives. If it does not come from our personal bank accounts or that of our insurer, be it public or private, we pay for it through charity, indigent care or other accounts. We are all our brothers’ and sisters’ keepers, and their health influences our health. The sooner we recognize these truths, the sooner we will truly make our citizens strong and healthy.
Harry L Gewanter is a pediatrician and pediatric rheumatologist. He recently retired from clinical practice to focus on Medical Home Plus, a nonprofit organization he co-founded.
Editor's note: Since Republicans withdrew their proposed health care overhaul, the American Health Care Act, on March 24 (after our April issue went to press), we asked Dr. Gewanter for his reaction. He says, "My hope is that the basic principles of the ACA will be kept in place and it will be modified and improved. I hope the governors and states will step up against the federal rhetoric and there will be a compromise package that continues to provide care for most, if not all, Americans. I hope that a discussion might start to discuss the underlying drivers of health care costs (insurer administrative costs, paperwork, unregulated pharma pricing, etc.), as that will prove better for everyone. I fear, however, that the siloed thinking of the politicians (and citizenry) will shred health care to the point that it will take years to recover. ... The verbal bludgeoning of the ACA will likely become a self-fulfilling prophecy as the legislative and executive branches “starve the beast” in an alternative means to achieve their goals. This will leave the private and public health care markets in confusion (remember that private insurers have to decide within the next few months on their charges for 2018) and no one comes out well in that scenario."
We Can Do Better
Ending mandates, providing incentives will lead to less expensive care
By Dr. John O'Bannon
We have a great opportunity to improve the affordability and accessibility of health care in the United States by repealing and replacing Obamacare.
The history of Obamacare, also known as the Affordable Care Act (ACA), is a cautionary tale on how not to enact change. Approved solely with Democrats’ votes in Congress, it was the largest-ever expansion of central government control of your health care. The plan was saddled with employer and individual mandates, 28 new taxes and massive new regulations.
It is important to remember that six deep blue states had chosen to expand Medicaid to Obamacare levels before the bill passed. The ACA’s Medicaid expansion effectively allowed these states to pass the expense of their coverage on to the federal government. In contrast, the law penalized Virginia, which had been working to make its Medicaid program more efficient and frugal. Fortunately, the Supreme Court ruled Obamacare’s mandatory Medicaid expansion scheme unconstitutional.
The other portion of Obamacare intended to increase coverage levels, the exchanges, are also failing. Enrollment is off and many states are down to one insurance provider.
Rather than fearing what some assert will be the downside of repealing Obamacare, let’s examine the opportunities presented by replacing this failed program. We can now establish different policies to fulfill the law’s stated objectives: ensuring the affordability of health care.
For insurance to work, we must have portability. This will give people an incentive to maintain their insurance even when they change employers. An annual enrollment program and allowing some rate differences based on age will build a robust insurance market that will put patients in control of their health care and ensure they have positive incentives to buy and retain insurance. We can retain popular aspects of the ACA, like allowing children who maintain residence with their parents to stay on the family policy until age 26 and prohibiting exclusions for pre-existing conditions.
Ending the employer and individual mandates will improve onerous and costly aspects of the plan that have stifled economic growth. Just think of the benefits to the economy — and to low-wage workers — of ending the requirement that employers provide health coverage for anyone working at least 30 hours a week, which has the effect of limiting the number of hours a part-time employee can work.
We have a great opportunity to reform Medicaid with provisions to care for the safety net with high-risk pools, while providing innovative programs for the Medicaid population. Per-capita block grants also will allow us to more effectively offer our citizens better care with fewer restrictions. Oregon did a great job of sending the dollars to the communities and requiring accountability. We should also consider the Indiana model, which pairs a high-deductible plan with a health savings account (HSA). This allows Medicaid recipients to save their dollars and shop for better options.
Obamacare has failed. Now, people need to be open to changes that will give them incentives to purchase and keep health insurance. We can do better. And we will.
John O’Bannon is a neurologist and a Henrico Republican who represents the 73rd District in the Virginia House of Delegates.
Editor's note: Since Republicans withdrew their proposed health care overhaul, the American Health Care Act, on March 24 (after our April issue went to press), we asked Dr. O'Bannon for his reaction. He says, "I'm disappointed that we were not able to reach consensus on a way forward to repeal/replace/repair Obamacare. The debate is far from over, and I hope members of Congress will learn some lessons from this exercise. I firmly believe we can do better by substantial changes to the health insurance individual market and hope something will get accomplished."