Monday, October 14, 2013

What Now?

Republicans seem to have given up hope of blackmailing the Obama Administration into repealing the Patient Protection and Affordable Care Act (ACA). They're still muddling around trying to figure out what they can wrangle out of the Administration for ending the government shutdown. So, what now?

Well, given that the Republican tactic for repealing/de-funding the ACA have so far failed, they are moving ahead with their parallel effort of undermining it, by stripping out provisions that would save money or bring in revenue (including taxes on high-cost health insurance plans, medical devices, tanning salons, and capital gains and dividends). They will then point to studies that show health care costs rising, and demand repeal all over again. Fanatics don't give up.

The fact is, health care costs in the U.S. are bound to increase initially as millions of people (some 44 million Americans have no health insurance) gain access to health care by virtue of obtaining affordable insurance. This has been born out by the experience in Massachusetts, where near universal health care was instituted in 2006, and the state's costs rose to 15% more per person than the national average (although there's no way to know how much costs might have risen anyway).

It will be difficult to assess the benefits to the economy of a healthy workforce, and fewer visits to the emergency room -- the most expensive way to obtain care. In addition, assessing the cost savings from fewer people having to be hospitalized because they now have routine care will only be possible in the aggregate and then only over the longer term.

Facets of the ACA that attempt to control costs, such as "accountable care organizations" (a system that gives doctors more incentive to better manage their patients' care) and the Independent Payment Review Board (an organization formed to review ways to reduce Medicare costs), were targets of Republican hyperbole, including the infamous reference to "death panels."

In fact, Republicans made all sorts of outlandish, patently false claims about "Obamacare" in their attempts to move the public to act against their own self-interests. They were quite successful in doing this. A recent pole showed that 43% of Americans oppose the law. Interestingly, more oppose "Obamacare," than oppose the Affordable Care Act. Further, more people support provisions of the ACA, such as preventing insurance companies from denying coverage for pre-existing conditions, when they aren't told the provision is part of Obamacare. People are funny about the idea of a black president, especially the people who aren't black.

It is unlikely that a reasoned debate will ever take place in the halls of congress -- not a natural state of affairs in American politics. If it did, one of the questions that might be asked is, "What's a life worth?" How much are we as a society willing to spend to improve a fellow citizen's quality and/or length of life? Take HIV as an example. Antiretroviral (ARV) treatment has transformed HIV from a death sentence to a chronic condition, allowing people with HIV to live longer and healthier lives (Linnemayr, et al, RAND 2012). But highly active ARV drugs are expensive, about $15,000 per year per patient (an examination of why ARV drugs are so expensive is beyond the scope of this essay, but suffice it to say, "free market economics" is not part of the equation). Before the development of ARV drugs (the first was developed in 1987), treating HIV was cheap -- you got HIV, then AIDS, then you died.

Washington policy makers aren't thrilled by the relatively inexpensive cost of saving the life of an HIV patient, they're outraged by the cost of Antiretroviral Therapy (ART). Thus, the debate centers on whether ART should be covered under Medicare, or Medicaid, or Social Security for people on disability (SSI / SSDI). Currently, fewer than one in five (17%) people living with HIV has private insurance and nearly 30% do not have any coverage. This will change dramatically under the Affordable Care Act, and many on the right (especially the religious right) see this as another reason to oppose ACA.

A critic of the Affordable Care Act, who worked on George W. Bush's health care proposals, Phillip Swagel, wrote recently that, "The goals of the Affordable Care Act are laudable. But achieving them will require an honest assessment of both successes and problems, and a willingness to make adjustments going forward." Swagel does not see President Obama as willing to make such an assessment.

I think Swagel is right on the first count, adjustments going forward, and wrong on the second. It's the TEA Party coalition in the Republican Party, and by extension, the party itself, that won't be willing to make an honest assessment of the ACA and will instead do everything in their power to either kill it or cause it to fail. Why? Because they prize their ideology over the health of millions of Americans.

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