Obamacare is Coming, and the Sky is Not Falling

First the forces arrayed against it tried to defeat it but failed.  Then the cry was, "Repeal and Replace."  The question "Replace with what?" was never adequately answered.  And so the opposition moved on to "defund Obamacare."  After all, no legislation ever enacted by Congress and signed into law by the president can be implemented without funding, and that funding was not guaranteed in perpetuity in the original bill.  So perhaps we could pass a budget for the fiscal year about to begin without funding for the Affordable Care Act (ACA).  Or we could say we won't go along the next time we have to raise the ceiling on the national debt unless we abandon funding for the ACA.

What's so bad about the ACA?  Let me count the ways it will destroy our health care system, in the view of its detractors.

(1) It will put the government in charge of your health care.  This one is being promoted by a television advertisement described by everyone in the media as "creepy."  It shows a young woman in a doctor's office, apparently there for a certain kind of physical examination that is common for young women but has few (if any) fans, and the leering practitioner is wearing an Uncle Sam Halloween costume.  Needless to say, the woman in the commercial is instantly far less amenable to proceeding with the visit than she was at the start.

This makes me laugh.  Those of us in the health care industry know just how much the government is already in charge of your health care.  This is because the feds already have very extensive control over how health care is financed, and when you control that....  Well, this seems pretty obvious.  There are so many rules about what we can and cannot do that emanate from Washington. The degree of such control has been steadily increasing since the enactment of federal health insurance programs in the 1960s.

(2) It will create death panels.  No, it won't.  What it will do is quite far from that - and arguably falls quite short of what we should be doing in this area.  We spend a very large amount of money on end-of-life care.  A substantial part of that spending pays for care that is very unlikely to benefit dying patients.  It may prolong life without any meaningful quality.  It may prolong suffering without any sort of trade-off that the patient would find worthwhile.  The most common reason for the expenditure of vast sums for non-beneficial care is that no one spent time with patients and families to talk about options and how they fit with the patient's personal values.  In our health care system, the default is "do everything," and the default is what happens when the patient and family have not given careful consideration, with advice and guidance from a trusted physician, to what they really do and don't want.  In the early debates over the ACA, there were provisions that would have required doctors to talk to patients about such things, and from the reaction I thought euthanasia for everyone over 70 was the topic of discussion.  When I was a medical student I had a frank discussion with my grandmother about her options.  I knew what her state of health was.  I knew what CPR was like.  I thought she might not want it.  I talked to her about it at length, so she could give it some thought and make decisions about what sort of care she wanted.  Guess who else talked with her about such things?  That's right.  Nobody.  And in the 30 years since she died, little has changed.

(3) It will raise the cost of health insurance for everyone.  This one is rather more complicated.  If you currently are paying nothing for health insurance, because you choose not to buy it, your costs will certainly rise.  The idea here is that insurance is a mechanism for spreading risk, and risk cannot be spread equitably if some people opt out.  This involves a very direct trade-off.  If we say everyone has to have insurance, then we take away the only plausible excuse the insurers have for excluding sick people.  They say people will just wait to buy insurance until they need it, like someone who buys automobile insurance after his car is stolen or wrecked.  We wouldn't allow that.  So if we say everyone has to have health insurance, we can tell insurers they may no longer exclude people with "pre-existing conditions" - or charge them higher premiums, which can effectively do the same thing as denial.

In some states, current rates of denial of coverage exceed 30%.  The ACA will put an end to that, and requiring everyone to have coverage is essential to making that work.

Similarly, we must require everyone to have insurance at some basic minimum level.  Certain things must be covered, with reasonable limits on out-of-pocket expenses.  If we don't do that, then we have the same problem as when some people opt out.  My dad didn't have a very good opinion of mental health services. I think at some level he thought people with mental illness were just weak characters who should buck up and get a grip on life.  He didn't want to pay premiums for health insurance that included mental health services, which he was sure he would never need, to subsidize those who really just needed some life lessons or a sympathetic ear.  And there we have the same problem: if we allow those who think they don't need coverage to opt out, we're not spreading risk effectively.

The same principle applies to "catastrophic coverage."  If I can afford to pay $50,000 a year out of pocket for health care, I can find a really cheap policy to cover me for expenses beyond that, because the actuarial risk that the insurer will ever pay anything is low.  But very few people can accept risk of that magnitude.  If the system lets me do it because I can, then once again risk is not being effectively spread.  So anyone who currently has coverage that doesn't kick in until spending is in the catastrophic range is going to pay more under the ACA.

On the other hand, many low-income folks will qualify for Medicaid who currently have nothing.  And many more who aren't poor enough to qualify for Medicaid will be able, especially with the help of tax credits, to afford health insurance, when up until now it just hasn't been an option.  We tend to think of the ones whose employers haven't offered health insurance, but there are plenty of hardworking people who have had "access" to employer-based health coverage, but it has simply exceeded what they could afford to pay.  They will no longer have to go without, because under the ACA there is a limit on the percentage of your income that you're expected to pay for coverage before you qualify for a subsidy.

So we are requiring people who heretofore have opted out to enter the risk pool, and requiring people to buy health insurance that has a higher level of coverage than what they would otherwise have chosen, thereby making insurance as a mechanism for spreading the risk truly workable.  At the same time, we are adding people to the Medicaid rolls and subsidizing premiums for the working poor who are not quite poor enough to qualify for Medicaid (which will require expenditure of tax dollars).  What, then, are we doing?  Just ask Joe the Plumber: we are spreading the wealth around.

By now my regular readers know I'm innately conservative.  I think the government wastes a lot of money.  I like the Jeffersonian ideal of smaller, less intrusive government.  I believe in personal responsibility.  So why on earth would I like the ACA?

In all honesty, I don't really like the ACA, because I believe the goal is universal coverage, and this will leave us well short of that.  We will still have at least 20 million without health insurance coverage.  That is my best estimate.  Call it pessimistic, but I prefer to be pessimistic and then be pleasantly surprised if things go better than I though they would.  This means I have to "like" the ACA because I am not willing to let the perfect be the enemy of the good.

Does it spread the wealth around?  Absolutely.  Will it personally cost me more in health insurance premiums, or taxes, or both?  Guaran-damn-teed.  So why am I for it?

I have spent the last 30 years practicing medicine and observing a very painful fact of life.  I live in the wealthiest nation in the history of the world, a nation that is at the same time the only modern, industrialized nation on this globe that fails to provide a universal system of health care.  Every single day of my working life I am face to face with people whose health has been neglected because the resources are simply not available to them to tend to it.  The consequences of that neglect land them in the emergency department, far worse off than should ever have come to pass.

Eighty-five percent of Americans have health insurance.  Many of them really don't care about the other 15%.  I am ashamed to live in a society where that is true.  I am heartened by the thought that those of us who do care are in the majority.  The latest public opinion polls say more than 60% oppose the "defunding" of the ACA.  Maybe many of the other 40% dislike the ACA for other than selfish reasons.  But to those who oppose it because they do not support the ideal of decent health care for all as a societal responsibility, I say shame on you.

 

Syria: A Stamp of Disapproval?

Bashar al-Assad has been directing the use of chemical weapons against his own country's people, in violation of "international norms" - and of an agreement to which Syria is not a signatory.

The "international community" is outraged.  Let me point out that there really is no such thing as the international community outside of works of fiction.  There is an organization called the United Nations.  It is ineffectual and often ignored, but it actually exists, unlike the "international community."

So what about that outrage?  If the outrage is international, what sort of international action is planned based on the outrage?  Right.  None.  The UN is doing nothing.  There is no "coalition of the willing." The French support action by the United States.  That's worth something, I suppose, given the Franco-American friendship that goes back to the 18th century.  But it's hardly tangible.

So what are we going to do?  The president is talking about using Tomahawk cruise missiles, perhaps 200 of them, at a cost of about $1M apiece.  That is a $200M Stamp of Disapproval.  At what will we target them?  Chemical weapons stockpiles?  Obviously a bad idea, the notion of blowing them up and dispersing sarin gas across the countryside.  How about the manufacturing facilities?  Well, they're buried underground, where cruise missiles don't reach, and they're probably buried well enough that our supply of "bunker buster" bombs, which haven't been upgraded in the last decade, won't be effective.  We could disrupt "command and control" - for a few weeks, maybe.  Not exactly a well-chosen objective.

We're not aiming for regime change, which is just as well.  What we'd like in Syria is a secular democracy, such as one finds in any number of other countries in the region.  That number happens to be one, and it's Israel.  The idea of secular democracy is about as likely to catch on in the Arab Middle East as Miley Cyrus is to be invited to put on a "twerking" demonstration at the Saudi Royal Palace in Riyadh.

So just what is the objective?  Two days from now, on the eve of the twelfth anniversary of the attacks on the World Trade Center and the Pentagon, President Obama will address the nation on prime time television.  Presumably he will answer that question.  Until then, I am left to speculate.  And, as my daughters and other young adults might say, "I got nothin'."  At least nothing that makes any sense or seems achievable.

We certainly cannot look to the examples of Afghanistan, Iraq, or Libya to find good results, but then when you are presuming to choose among various groups who all despise the Judeo-Christian West and its values, you really cannot expect to accomplish good things (from our perspective) by replacing one with another.

Why do we care about the ghastly happenings in Syria enough to risk initiating a large-scale regional war?  In 1994 in Rwanda, half a million people were killed in a genocide of shocking proportions over a period of one hundred days.  And we did ... nothing.  The "international community" also sat on the sidelines.  Oh, that's right, it created the International Criminal Court, which has been marvelously effective.  In the decade since its creation, it has yielded one conviction (now being appealed).  President Clinton has described US inaction as one of his administration's major foreign policy failures.  Hello, Captain Obvious!

But we don't really care about Africa, do we?  It's the Dark Continent.  That makes it easy for us to pretend we don't see what happens there.  There isn't any oil (except in Nigeria).  Geopolitical instability there doesn't seem to affect US interests.  The Mideast is another story altogether.  Lots of US interests there. The world's economy is very directly affected by the stability (or lack thereof) of the region.  So, if anyone tells you that our interest in stopping the killing in Syria is humanitarian, repeat after me: "Yeah, right."

So the president may be able to convince us that important US national security interests are at stake in the region and that intervening in some fashion in the Syrian government's appalling attacks on the country's own population will serve American purposes.  I've been trying to connect those dots since this became the lead story in every day's news reporting, and I'm still not seeing it.

I don't see how we will do anything to stop Assad's war crimes.  I don't see any prospects for starting Syria on a path to becoming a secular democracy.  And I think those are the only two goals worth pursuing.  The president has not made his case yet.  Most surveys of public opinion show that his style of "leading from behind," as it is derisively called by Republicans, has convinced very few Americans that his plans for intervention make any sense at all.  I'll be working Tuesday evening, but I expect to watch him later, courtesy of my DVR, or at least read his speech online.  I'm openminded.

Mr. President, you got some 'splainin' to do.