Despite the constant refrain heard from many (particularly
Republicans, particularly in Congress, and particularly from the particularly
self-promoting Sen. Ted Cruz of Texas) that “ObamaCare” (the Affordable Care
Act, ACA) is the first sign of the coming apocalypse, and concerns from people
like me that it is a great deal for insurance companies and will still leave
many people without coverage, it is going to happen and it is going to be a
good thing for the health of many people. It’s too bad that the crêpe being
hung by the nay-sayers is believed by so many, largely a result of it being so
well funded. Of course, this doesn’t mean that Sen. Cruz is going to change his
tune or that I am going to stop worry about those who continue to be without
insurance (especially in states that don’t expand Medicaid, like mine).
Some have suggested that the biggest fear Republicans have
is that it will work, and people will benefit, and that now is the time
to scare people to try to get rid of it, since once it is in place people will
not want to give it up (see: Medicare). Right now, satirist Andy Borowitz can
make fun of the right’s hyperbole with bits like “Fox
News: Obama In Plot To Force Americans To Live Longer”, but when people
actually do get health care, and the
costs do go down, and maybe they do live longer, or at least live in
better health (longer “healthy life expectancy”, or HALE; see The
State of US Health: improved over 20 years, but not nearly enough”, July
14, 2013), they are going to be happy with it. When you can get health
insurance even though you have a pre-existing condition, when you can get
health insurance on the exchange marketplace even though your employer hasn’t
offered health insurance to you, when you can afford the premiums because those
between 133% and 400% of the poverty level will get federal subsidies, it is
not likely to make you unhappy and you are very unlikely to want to give it up.
Of course, those who are under 133% of poverty were to have
been covered by Medicaid expansion, and this is not going to happen in a lot of
states, so these folks will be left out. Chang and Davis, writing in the Sept-Oct
issue of the Annals of Family Medicine
examined “Potential Adult Medicaid Beneficiaries Under
the Patient Protection and Affordable Care Act Compared With Current Adult
Medicaid Beneficiaries”.
Using a large federal database (NHANES) they compared over 13 million people in
each category, and found that the potential beneficiaries were more likely to
be male and white and to have about the same level of educational attainment as
current recipients. They also had better self-reported health status, and were less
likely to be obese or depressed. The prevalence of diabetes and hypertension
were about the same, and the potential beneficiaries were more likely to be
smokers and heavier drinkers. So, in general, expanding Medicaid to this larger
population would result in a healthier (and thus less costly) group to care
for, although with significant risk factors. This is related to the argument I
have for expanding Medicare to include everyone
(a single-payer health system): the highest cost utilizers, the old and
disabled, are already in it and expanding it will, thus, not cost as much more
as one might think (or certainly not as much as using the private insurance
market as we currently do, or even under the Obamacare expansion).
Two editorials
accompany this article. Danel Derksen discusses how the ACA will offer opportunities for
(and challenges to) both family physicians and public health, while J.P. Silvers
compares the objectives of
the plan and the results that it is likely to achieve in the real (“imperfect”)
world, with emphasis on the potential for “market failure” as the limiting
factor. He lists the 3 main objectives of the ACA as 1) reforming the private
insurance market, 2) expanding Medicaid, and 3) changing the way that medical
decisions are made. The first, the effort to get those currently left out of
the insurance market primarily because they are self-employed or work for small
companies, is to be accomplished by the subsidized health insurance exchanges,
with quite significant subsidies; the idea is that competition will lead to lower
prices and better coverage. If this doesn’t happen (“market failure”) then the
goal is not going to be achieved. So far, I note, in most states it seems to be
working.
Expansion
of Medicaid to cover people who are below 133% of poverty and yet not currently
eligible was a cornerstone of the program, and the one that the Supreme Court
made optional; per this map from the www.Bankrate.com
website, 23 states + DC will be expanding Medicaid, 21 will not be, and 6 are
undecided. The fact that the federal government will be paying for it seems to
have convinced several Republican-controlled states (e.g., Arkansas, Kentucky,
North Dakota, and Arizona) that it would be a good idea. Of course, it is a good idea, and not doing it is a way for those who are themselves “feeding at the
public trough” (legislators who get publicly-funded insurance) to punish the needy,
falsely cloaking themselves in the language of conservatism. As Silvers notes,
to really improve health, Medicaid rates will need to be high enough that
providers will actually care for beneficiaries.
The third area is changing
medical decision making, to both improve the quality of care and lower the
cost, issues about which I have often written (see, for example, Controlling
the cost of health care by doing the right thing, Sept 22, 2013). Silvers
cites, in particular, comparative effectiveness research (CER) which will show us
which things work and which things cost the least to achieve comparable
results, and which, it is to be hoped, would actually change medical practice.
He then goes on to describe the factors which exist in our “imperfect world”
that threaten the achievement of these goals, because “There are serious problems in the way the US health system is organized
and paid, in the information and choices available, and in the ability of
participants to respond to the pressures and incentives provided in reform.” The
three classes of problems he discusses are “when
decisions are delegated to someone who is supposed to act strictly in our
interest as an agent, but doesn’t”, such as brokers who are paid
commissions from someone else for signing us up; limits on potential
competitors (as arising from pharmaceutical patent protection); and “when one party in a transaction has
differential information that allows them to dominate or exploit decisions”, in
play with regard to physicians, hospitals, drug companies, insurance companies,
and almost everyone involved in health care compared to regular folks. He notes “Finally, the plethora of perverse payment
incentives is the most obvious problem in having informed free choice leading
to the optimal outcomes desired.”
And this is the real point. The web of multiple strategies
for achieving coverage are incredibly complicated, with roots in both the
Clinton plan and Massachusetts’ “Romneycare’ and (ironically) in the ideas of
right-wing think tanks over the last several decades. This patchwork of fixes
has always been a Republican (and conservative Democratic) hallmark. While
Silvers titles his final section “What does it mean for the future and what can
be done?”, in fact he mostly tells us what the risks are rather than what could
be done. There are many who suggest (or fear) that the biggest threat from a
potential failure of Obamacare would be that it would make the fact that a
single-payer system would be much simpler and effective more obvious; see
Morici “First Obamacare,
Then a Single Payer System” on www.breitbart.com,
cited by Don McCanne in Quote
of the Day.
That’d be nice.
2 comments:
There are many serious facts in way of Public Health:- (Indian Experience)
1.Government Hospitals are in poor health, doctors and staff paid from public tax work very poorly, very carelessly and irresponsibly. Most of them do private practice at other places in free hours and even on their hospital duty hours.
2. Private sector is free to decide their fees and rates, so they are free to loot.(Government policy is that competition will reduce the fees, but practically it does not happen)
3. Pharmaceutical companies are a big lobby to determine the government policy in deciding medicinal rates. So patients pay always much much more than their actual costs.
4. Medical and Health insurances, either purchased by peoples themselves or arranged by governments for certain group of people, are always exploited by Private hospitals and Insurance companies when patient reach hospital.(Insured patients pay more for the same procedures than un-insured patients)
5. I suggest that Health sector must only be in government sector and their must be no place for private sector in health.
Dr. Ravinder S Mann
Could you talk a little bit about how a single-payer system, or even the ACA, might adjust the way that Relative Value Units (RVU) are created and utilized by the health care system? I feel like without reform of the the RVU process, there is still self-promoting, systemic exploitation of the medical field, no?
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