Sunday, July 24, 2016

President Obama on the ACA and next steps: what do we really need to improve our health?

On July 16, 2016, the JAMA took the unusual step of publishing an article by the President of the United States. “United States Health Care Reform: Progress to date and next steps”, by Barack Obama, JD, is by definition “political” and a defense of his administration’s health care policy and achievements, but it is also a well-documented piece of policy research. In it, the President details the improvements in both health care access and actual health status achieved by Americans since the passage (in 2010) and largely-full implementation (in 2014) of the Affordable Care Act (“Obamacare”), and provides evidence to support the central role of the ACA in creating those positive changes. He particularly notes that this improvement is not simply a result of improvement in the economy recovering from the Great Recession of 2008; this is supported by the fact that many indicators of breadth of coverage (what percent of people had health insurance), quality of coverage (how good was it), cost of coverage, and quality of care were getting worse for a long time before 2008.

The President provides data to demonstrate the increase in the number of insured people, especially in the 31 states that have expanded Medicaid. But coverage has expanded even in the others, due mainly to the availability of coverage on the Health Insurance Exchanges, the decrease in cost despite dire predictions for rate increases by insurers, the move (seen variably across the country) away from fee-for-service and towards comprehensive care reimbursement for health care providers, the decrease in the Medicare drug coverage (Part D) “donut hole”, the improvement in health status and quality outcomes from greater tobacco control, and many other positive results of ACA.

President Obama also bemoans the changes that the ACA was unable to achieve because of Republican opposition (while this could be perceived as partisan, it is fact, and fact strongly acknowledged by the Republican Party which has voted to repeal ACA dozens of times). He ends with a lengthy plan for the future, a future in which he will not be President, and what yet needs to happen to improve health and health care in the US. This includes the expansion of Medicaid to all 50 states, increasing competition in the marketplace so all Americans have access to a choice of plans, and limiting the control of special interests, especially drug companies:
The second lesson is that special interests pose a continued obstacle to change. We worked successfully with some health care organizations and groups, such as major hospital associations, to redirect excessive Medicare payments to federal subsidies for the uninsured. Yet others, like the pharmaceutical industry, oppose any change to drug pricing, no matter how justifiable and modest, because they believe it threatens their profits.

While the President does not call out the insurance industry as he does the pharmaceutical industry, he renews the call for a “public option” to compete with private insurance companies. He stops short of supporting a single-payer system, invoking “pragmatism” (defined as “we have to find something palatable to those who oppose change because they are doing so well now") “Simpler  approaches to addressing our health care problems exist at both ends of the political spectrum: the single-payer model vs government vouchers for all.”

When I am confronted by this pragmatism argument, I am somewhat sympathetic. Given the opposition both from Republicans in Congress and entrenched, wealthy and powerful industries (not only pharmaceutical and insurance, but also providers), the passage and implementation of the ACA was a formidable victory. All of the data cited by the President is true, and almost all of it is good. More people ARE covered, the quality of their coverage has improved, the cost to the system (and in most cases to individuals) has gone down, and there have been positive developments in the areas of quality improvement, fraud, and value, and moves away from fee-for-service to comprehensive care. The President led this effort and has the right to be proud, but the holes in the health system that remain are still very large.

For many people, good health insurance coverage is unaffordable; they buy policies on the exchanges that do not cover their needs when they get sick. For many others, there is still no coverage – most of those below 137% of poverty in states that have not expanded Medicaid, those without legal documentation, and some others. The powerful provider, insurance, and pharmaceutical industries have an outsized voice in determining health policy. The disorganized and fragmented nature of our health system and piecemeal nature of coverage and incentives for coordination of care, even with the ACA, lend themselves to healthcare industries (including doctors and hospitals) finding “work-arounds”, or “gaming the system”, for their self-interest.

The key, essential issue in considering past, present and future healthcare and health insurance reform is whether the goal is to maximize the health of the American people or something else (mainly, as I have suggested before, industry profit). There is a cohort of politicians, pundits, and commentators, who are ideological devotees of the unfettered market (and of Ayn Rand novels) who actually are against maximizing health for all; they may be unusually influential, but they are few. There is a larger group, the corporations who are believers only in their making profit, which means the free market only when it advantages them and government support of their industries when that advantages them. And, of course, there are the many politicians and pundits who are on their payrolls, direct or indirect (e.g., campaign contributions). Their role has always been powerful and is greater since the Citizens United Supreme Court decision that said corporations are people and money is speech.

But the largest group is regular people, trying to get by and trying to make sense out of these purposely-obfuscated policy issues. They include folks with and without insurance, like those who are interviewed by Dr. Paul Gordon on his Bike Listening Tour across America, who say things like “Obama Care helped the poor, but now the working class is struggling”. People who are trying to figure out what kind of insurance to purchase on an exchange, and very often opt for the plan with the lowest premiums that will take the least out of their monthly income so that they have more for food, housing, and other necessities as well as some entertainment or relative “luxuries”. And who only find out when they get sick how bad that coverage is, and how much debt they are going to be in, because they lost that gamble.

The reason for this is that, as I have often discussed (perhaps first in “Red, Blue, and Purple: The Math of Health Care Spending”, October 20, 2009), most people are, at any given time, not sick. Most people, especially younger people, will not be sick at any time for the whole year, or a number of years. Thus spending high monthly premiums for good (or better) coverage seems like a burden, and it is. Until, of course, they get sick. Until they get cancer, or get in a car wreck, or have a premature baby, or find their hitherto pretty-well-controlled chronic diseases spiraling downhill. Advocates of consumer choice may say “tough luck, that’s the market”, but this is people’s health. Consistently, surveys of the American (and most other) people find that the vast majority want everyone to have access to high-quality care when they need it – and even want it for “other people” that they don’t know. But the solution, even with ACA, forces them to gamble on their future health while ensuring that insurers and drug makers and the biggest healthcare providers make money. It is a plan to create fear and anxiety and insecurity, despite the accuracy of the overall improved health, and financial, picture that the President paints in his article.

There is a solution. It is indeed a single-payer system. One where everyone is covered, and pays what their incomes can reasonably afford, where the whole society is the risk pool rather than the individual, and people don’t have to gamble with their future health. We could have that, and most of us would relish it (like the vast majority of citizens of other developed countries who have it), and it would provide our only reasonable hope of truly controlling cost and improving quality.

But we are going to have to fight for it. Power does not relinquish control and money easily.

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