Wednesday, January 19, 2011

Telling the Truth about Health Care

I admit that I couldn't get through all seven hours of the House debate on HR2, the Republicans' bill to repeal the Affordable Care Act. I had to give up during hour four (two and a half hours yesterday and nearly two today) when the talking points were simply repeating themselves. We'd entered that point where everyone had to give their one-minute speech that would get them on the local news. (For all the talk about changing the filibuster rules in the Senate to allow better decision making, we really need an approach to "debate" in the House that gets to more than dueling talking points.)

The bill passed the house by a vote of 245 to 189, with Republicans voting 242 to 0 and Democrats voting 3 to 189. It stands little chance of coming up in the Senate, less chance of passing if it does come up, and faces a sure veto by President Obama.

With that behind us, we can go back to remembering what is true about ACA. I've posted these things on Facebook before, but thought it would be good to put them all in one place.

ACA is NOT a government takeover of Health Care. This was determined as "the big lie of 2010" according to Politifact. Talk about "putting bureaucrats between you and your doctor" is the status quo. The federal government creates incentives for states to establish exchanges for those people not on employer-based insurance. It's true the states represent governments, but this certainly isn't a national takeover (Reagan called it "New Federalism").

It is NOT a "budget buster". It actually saves money in the long run based on CBO estimates. It begins to slow the growth curve on costs, which increased 131% between 1999 and 2009. It is true that costs have gone up since the passage of ACA in March, but the full implementation doesn't occur until 2014. The costs have regularly been increasing. There is an additional piece I've been thinking about. One of the new restrictions is that insurers must spend 85% of their revenues on actual medical care. I believe the cost increases this year are an attempt to maximize what the base is before the 15% overhead limit kicks in. It's not a sustainable growth curve but more of a one-off.

The "American People" HAVE spoken on the Law and they DO NOT support repeal. Recent data  demonstrates that there are significant partisan divides on the question. According to the Kaiser Family Foundation, 55% of Republicans do support repeal. But only 26% of all those polled think so. The remainder want some parts adjusted, think it's a good thing, or are unhappy because it didn't go far enough. This may indicate that our political discourse has gotten so one-sided that we only listen to our most ardent supporters and think they represent the people as a whole. When you look at the individual components of the law, they are very popular even among those calling for repeal.

Medical malpractice reform WILL NOT solve the cost issues. I don't think it would hurt the Democrats to give in on this one, but it's not significant. In response to a request by Sen. Orrin Hatch in the fall of 2009, the CBO estimated that fixing frivolous lawsuits would reduce medical costs by one half of one percent. To put that in context, if you spent $300 per month on insurance you'd only have to spend $298.50. It may be true that doctors practice defensive medicine (additional tests, etc) to protect themselves against lawsuits, but the Effective Measures review (that gets called a door to rationing) would likely provide tremendous protection against those lawsuits.

The law has NOT been declared unconstitutional. One judge is opposed to the individual mandate (and there are legal scholars who challenge his logic) but left the law standing. The other judges to review constitutionality upheld the law. The commerce clause allows the regulation of proper interstate business. (By the way, the Republican strategy is to require shopping across state lines, which besides creating a "race to the bottom" would apply the same logic.) This will be determined in the Supreme Court and "if" the decision is made on established law, it will be upheld.

So what is this about? It's a major philosophical disagreement over the nature of health care. This morning, one of the new Representatives from Indiana, Todd Rokita, stated his position clearly -- "Health Care is Not a Right". Position like his see health care as a commodity that one purchases from the private sector. If you have sufficient means, you get better care (which is why there's been a big fight over "Medicare Advantage" or "Cadillac plans"). This is why the Republicans are concerned about individuals being forced to purchase care "against their will". I really don't understand why folks worried about immigrants using public services are comfortable with the uninsured getting care from emergency rooms and relying on the pro-bono write offs of local hospitals.

Democrats like me look at this differently. I'm concerned about those who gamble with their health for financial reasons until the situation is chronic. Then they get care too late so that the costs are much higher. Those costs get factored into everyone's health costs (the hospitals aren't giving stuff away). So caring for the poor and sick represents the common good. More importantly, it becomes a moral imperative because of our expectations about what a healthy society looks like.

The Republicans will now try to limit the implementation of ACA, as is their right. As they say, elections mean something. Of course, the 2008 election is why ACA was legitimately made law and will remain so since they didn't win the Senate. Republicans do appear to be in favor of the reforms people like (portability, no limit on pre-existing conditions, children on parents' insurance, etc.) but have no plan for how to get there or how to finance it.

There is much to address in ACA going forward. The exchanges will need to be evaluated. Adjustments will be made this year to the 1099 reporting requirements for small businesses. It will take time to move from chronic response to preventative care. It may take a decade for the deployment of medical professionals to match the need. And there are still nearly 30 million people uncovered. But it's the right direction, as Ezra Klein explained the other day in the Washington Post. In the end, that's all we can do in terms of finding the balance between individual freedom, states rights, crisis management, and fiscal health, while pursuing that "more Perfect Union."

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