The only way out

By Louis Balizet, M.D.
Health Policy Solutions (Denver), Jan. 9, 2014

The Affordable Care Act, while providing some short-term benefits, is, on the whole, unworkable. Quite apart from website failures, its approach to health care is fundamentally flawed. It is exceedingly complex. It perpetuates and entrenches the inefficient insurance model of payment for health care. It does nothing to address the rapacious pricing of pharmaceuticals. It ignores hospitals’ “medical arms race,” in which they expand facilities and services based not on community need, but on potential for profit. It still burdens doctors and hospitals with multiple payers, abstruse coding and insecurity about payment for delivered services. It is subject to state-by-state sabotage. At its most optimistic projection it leaves at least 25 million people uncovered.

Despite three years of preparation, the Affordable Care Act (ACA) is beset by delays, multiple exemptions and computer failures. The Obama Administration celebrates the enrollment of 2.1 million persons in private insurance through the exchanges.

The Centers for Medicare and Medicaid Services, meanwhile, has been cagey about how many of these 2.1 million have actually established a contractual arrangement with an insurance company. This has led to speculation that the number is quite small.

As recently as two months ago, the digital conduit that connects exchanges to insurance companies was described as “under construction.” Repeatedly postponed deadlines have insurance companies scrambling to send bills, register payment and validate coverage. With opening day now behind us, it is likely that hundreds of thousands will find themselves stranded at second base – exchanges negotiated, but insurance not issued.

Many of those who have secured coverage will discover that it is very thin coverage indeed, especially those with bronze plans. These plans approximate “junk insurance”: prohibitively high deductibles and co-pays combined with shrinking provider lists. Insurance companies that have elected to participate in the exchanges may find themselves in actuarial hot water and will raise premiums, further trim provider lists or fold altogether (especially the newly-formed co-ops). This year and especially 2015, may make October through December 2013 look like halcyon days.

The multiple failures of the ACA should come as no surprise to anyone familiar with its sordid political history. Sen. Ted Kennedy’s untimely death deprived the U.S. Senate of a powerful member who was at once its chief expert on health care policy and a decades-long advocate for universal health care. Health care leadership defaulted to Montana Sen. Max Baucus, ill-suited by inclination and background to fashion true reform.

Barack Obama acted less like a president and more like a community organizer as he failed to propose a coherent plan of his own. Into this policy breach stepped special interests, most prominently insurers and Big Pharma; any pretense of universal coverage and bona fide cost controls soon disappeared. What emerged was the euphemistically entitled the Patient Protection and Affordable Care Act, a Rube Goldberg contraption that befuddles experts to this day while richly rewarding those who got in on the ground floor.

What are the alternatives if the ACA craters? This is not a hard question to answer; examples of much better systems abound.

Virtually all other developed nations provide universal health care at two-thirds or less than our cost, with equal or better outcomes. The U.S. spends 17.7 percent of its GDP on health care, and its residents experience a life expectancy of 78.7 years. The corresponding values for France are 11.6 percent and 82.7 years, for Canada 11.2 percent and 81.0 years, and Australia 8.9 percent and 82.0 years.

What these and more than a dozen other countries with similar figures have in common is government-provided or facilitated universal health care, financed by a variety of taxes (income, payroll, sales) without reliance on American-style insurance companies. America should learn from these countries, not ignore or deride them.

The only way out of our currently costly and shameful health care quagmire is single-payer, tax-supported, improved Medicare for all. Medicare is a tax supported single-payer plan that has provided access to health care to tens of millions of Americans over 65 or with disabilities, with 3 percent overhead for close to 50 years. It would need to be altered, however, before universal application. Right now it is partially privatized, with Part B supplements, Part D drug coverage and Medicare Advantage. Involvement of private insurance companies makes it unnecessarily complex and unacceptably expensive. These concessions to private industry have to be eliminated and benefits expanded to include more complete outpatient care and drug coverage.

The statutory prohibition of system-wide government drug purchasing, embedded in George W. Bush’s Part D legislation, would have to be repealed. Medicare must be empowered to pay hospitals by an annual global budgeting process rather than the complex, costly piecemeal process currently in place. Doctors would have to be fairly compensated and not threatened annually with draconian cuts in income. For all the alterations that would be necessary, Medicare is still a far superior foundation on which to build a universal health care system, compared to the cacophony of hundreds of insurance companies we now contend with.

The flagrant failures of Obamacare, past and yet to come, would seem to argue against trusting the federal government to run a project with the scope of Medicare-based universal health care.

What is indisputable is that neither our government nor any other should attempt to implement a fatally flawed project. The U.S. military provides valuable lessons in this regard. When given an achievable goal and a sound strategy, it produces remarkable results (World Wars I and II). On the other hand, when it is asked to execute a flawed policy, disaster ensues (Vietnam, Iraq, Afghanistan).

No one can discredit the U.S. military on the basis of these failures; rather, blame is rightfully placed on the elected officials who asked the military to attempt the impossible. Likewise, our government should be reasonably expected to achieve what other governments have shown to be achievable – universal health care without breaking the bank. Obamacare’s failings should not blind us to this realization. In fact, there is no option other than improved Medicare for all. It is that, or fiscal and moral Armageddon.

Louis Balizet, M.D., is a recently retired oncologist from Pueblo. He’s a member of the advocacy group, Physicians for a National Health Program, and a leader of Health Care for All Colorado.