Covering the Uninsured
Like many, I rejoiced at the news of the Supreme Court’s decision upholding the individual mandate and the key provisions of the Patient Protection and Affordable Care Act (PPACA). As a doctor and medical ethicist, I think it is an important step in healthcare reform.
And it is now certain that the presidential election will hinge at least in part on health reform. Voters will have a clear choice on the PPACA: Romney will repeal, and Obama will implement. Which do you want, America?
President Obama and his supporters tout the law’s promise to make affordable health insurance available to many of the 32 million Americans who do not have medical insurance. This is a terrific accomplishment, as are the protections for those who already have insurance, such as eliminating limits on lifetime claims.
At the same time, for the ensuing political debate and the evaluation of the PPACA overall, much more than these accomplishments have to take center stage. Focusing on the uninsured will not win over the electorate. Too many Americans who vote have insurance, and are not fearful about losing it, so the plight of the uninsured is one step removed.
The Elephant in the Room – Cost of Healthcare
Instead, the cost of healthcare is the elephant in the room. The healthcare budget has been increasing faster than the economy for more than 50 years and there is no end in sight. Spending on healthcare now comprises 18% of GDP and continues to grow. Nobody believes that this is sustainable. Democrats and Republicans disagree about how to curb the growth (more on this below) but not that it is necessary to do so.
The growth threatens to upend the federal budget as well as state budgets by causing unsustainable increases in Medicare and Medicaid spending. And it weakens American business. As long as the expense of providing healthcare insurance for your employees is large and growing out of control, it is difficult to hire or to compete with businesses in countries with affordable healthcare.
Obama took on healthcare reform, according to all reports, at least largely because he saw that allowing this growth to continue was simply irresponsible. And he eventually settled on the individual mandate as the essential first step. Once everybody is contributing, and everybody has health insurance, one can start the process of rationalizing and controlling the system.
It would be great if we could control cost without first getting everybody into the system, but that isn’t going to happen. Heck, even Romney knew that when he was governor of Massachusetts, which is why he supported the individual mandate then. The current Republican “proposals” (yes, they do deserve quotation marks) have no hope of achieving this important aim.
It’s necessary that Obama and other defenders of the PPACA make this argument, and own this aspect of the law, since if they do not, they are ignoring a very real concern about its effect on the budget, at their peril.
Critics of the ACA point out that simply making people join a system that is out of control is like putting your foot on the accelerator of a truck with no brakes. The idea that providing insurance to the uninsured will by itself control costs, by simply getting them to treat health problems before they get serious, is not well supported by the literature. Many preventive measures save lives, but even the best mostly do so at some expense, rather than also saving money.
Instead, Obama and the ACA supporters should be honest that getting everybody (or, almost everybody) insured was simply the first step in controlling costs. Once everybody is in the system, we can make changes that can finally adjust incentives in ways that reward providing essential, cost-effective care rather than providing inessential, expensive care.
As Atul Gawande pointed out in an excellent article in the New Yorker in 2009, the PPACA includes massive numbers of pilot projects to explore ways to improve care and control costs at the same time. Approaches have to include all good ideas, many of which are not possible without a system that includes all possible patients.
As Obama used to emphasize, it’s about finding ways to “bend the curve,” and slow the increase in healthcare spending, not reducing spending from current levels. We don’t have to give up what we have to control spending. In fact, the best way to make sure that we will have to give up what we have is to let prices continue to go up in the future, until even the middle class cannot afford the cost.
But that means that Obama and his team have to explain the sort of mechanisms that we can hope will allow PPACA to lead to truly “Affordable Care” not just subsidized care. They must admit that these mechanisms are still uncertain but at least hold out the best hope of finally controlling costs, to keep the newly insured insured, and to save American medicine.
Can Obama Avoid this Argument?
Some political pundits or advisors will say that Obama should just focus on the easy wins in the law, such as covering the uninsured, eliminating lifetime limits and cost adjustments based on new or pre-existing conditions, allowing young adults to stay on their parents’ insurance, and eliminating the doughnut hole in pharmaceutical coverage for seniors. Why admit that there is a big challenge that comes next, and that the law just sets up the country for having to make decisions to control costs?
The short answer is that you can’t avoid it and addressing the question. Americans know that you can’t get something for nothing. And the size of the federal deficit, and the criticism of federal spending in current discourse, has made it clear that money is not limitless.
If Obama didn’t want to have this discussion, and make this case, he shouldn’t have gone down this road in the first place. It’s “all in” in the poker sense, not just the solve-the-uninsured sense.
Ducking the questions is not honest, and it is not good politics. The discussion of the PPACA must include straight talk about how it will allow us to finally confront and address the ever growing health budget. Above and beyond celebrating the success in covering so many of the insured.
Peter H. Schwartz, M.D., Ph.D.
IU Center for Bioethics