GOP intransigence accelerates health care crisis

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, Jan. 31, 2014

The Affordable Care Act, President Obama’s health care law, will reduce the number of uninsured through an expansion of both private health insurance and Medicaid. When fully implemented five years from now, it is estimated the law will leave about 30 million people without any form of health insurance, a number that would have been lower had 25 states not “opted out” of Medicaid expansion.

In the meantime Republican lawmakers have continued to call for repeal of the Affordable Care Act.

The Republican majority in the House of Representatives has symbolically voted to repeal the law dozens of times — 14 times over the last year and 35 times during the previous Congress. The irony of voting to repeal a law that was initially a Republican and Heritage Foundation idea — the compulsory purchase of private health insurance —has been highlighted by the fact that Republicans have not seemed to have a counter-proposal, something with which to replace the Affordable Care Act.

This week, evidently in an effort to show they have an alternative, but implicitly acknowledging the ongoing health care crisis, three Republican senators put forward a legislative proposal they call the Patient Choice, Affordability, Responsibility, and Empowerment Act. The Republican senators’ proposal would still use taxpayer money to subsidize the purchase of private health insurance for those can’t afford it, but to a lesser extent than the Affordable Care Act now does.

Oddly, from the party where Grover Norquist’s “no new taxes” pledge is so popular, the Republican senators propose to tax health insurance benefits as income.  The income tax would be levied upon employees, not employers.  This stems from the erroneous theory that health care costs might be reduced if workers are compelled to choose plans with lower premiums, but higher out-of-pocket costs, like co-pays, co-insurance, deductibles.

Under the current law, Medicaid expansion was intended to help millions of people living at or near the poverty level obtain health coverage.  Yet Republican lawmakers in 25 states “opted out” of the expansion of Medicaid that the Affordable Care Act proposed. Had these 25 states implemented the law, nearly 8 million people, presently uninsured, would have gained coverage. The Republican senators would like to see even fewer people covered by Medicaid than their counterparts have allowed state-by-state.

Yesterday, a third-year Harvard medical student, Samuel Dickman, together with senior researchers from Harvard Medical School and the City University of New York, published a study that highlights the human toll of these political decisions.

If all states had “opted in” to the expansion of Medicaid coverage as the law was designed, 7,780,000 more uninsured would have gained coverage. Dickman and colleagues found that if these millions of people gained Medicaid coverage, at least 7,115 and perhaps as many as 17,100 deaths might be prevented.

It is important to state that Medicaid coverage is often inadequate. Medical specialty visits can be impossible to obtain and many states have very restricted access to prescription medications under Medicaid, for two examples. However, having Medicaid remains better than being uninsured.

Dickman also reports because 25 states “opted out” of the Affordable Care Act Medicaid expansion, more than 240,000 people will face catastrophic medical expenses, over 400,000 diabetics will lack access to medications, nearly 200,000 women will forgo mammograms and over 400,000 women will forgo pap smears.

It is not only that Republican intransigence against the Affordable Care Act does nothing to advance the national debate about health care in a direction that would improve quality, increase access or reduce disparities. Nor would Republican proposals offer any means of cost saving, for both out-of-pocket costs and aggregate spending would continue to soar.  It is also important to recognize that the decision to “opt out” of Medicaid expansion has a human toll. As Samuel Dickman said of his research findings, these “political decisions have consequences, some of them lethal.”

Unfortunately, because the Affordable Care Act will not extend coverage to all of the uninsured, is powerless to rein in costs, and keeps profit-seeking in the driver’s seat of the U.S. health system, it too allows an unacceptable situation to persist. Medicaid expansion would lessen preventable death in the United States, for example, yet tens of thousands would still die from lack of health insurance annually, even if all 25 states had “opted in.”

Our nation must move beyond a debate in which neither side will boldly state the obvious goal:  every person in the United States deserves equal access to all necessary health care.

Dr. Andrew Coates practices internal medicine in Upstate New York. He is president of Physicians for a National Health Program.
You can find an archive of Dr. Coates’ WAMC radio broadcasts here: