Among the people who express dissatisfaction with Obamacare (the Affordable Care Act), the bigger number are actually progressives who were upset by the contortions Obama went through to preserve profit-making private insurance companies as the gatekeepers to the health care system.
Progressives wanted a single-payer system which every other advanced industrialized country has. Because in essence, health care – life and death – is not a commodity subject to free market forces – consumers are in no position to shop around or make rational choices when faced with a health emergency, and in fact, there is no transparency or competition that would even allow a “free market” to exist.
What is more, Obamacare is focused principally on the problem of access to care – presently denied to 49 million uninsured people and millions more underinsured people for whom a single medical emergency can result in bankruptcy, but amazingly, a proportion that has remained consistent at 16 percent – rather than the cost crisis of health care.
The charge that Obamacare addresses access and not cost, is an essential aspect of the argument that Leonard Rodberg. professor and chair of the Urban Studies Department at Queens College of the City University of New York and Research Director of the New York Metro Chapter of Physicians for a National Health Program, presented recently to Reach Out America, a local activist group.
There is great bitterness in his tone – and the botched rollout of the exchanges because of glitches in healthcare.gov site only serves to be an “I told you so” because of a program that is unbelievably – and in progressives’ minds unnecessarily – complicated.
Indeed, his indictment of Obamacare as doing little to contain the inexorable rise in health care costs seems overstated, considering that health care spending is growing at the slowest rate on record and health care price inflation is at its lowest rate in 50 years, according to a recently released report from the Council of Economic Advisers on “The Recent Slowdown in Health Care Cost Growth and the Role of the Affordable Care Act.”
Keep in mind, the health-care exchanges have yet to be implemented, which for the first time will inject transparency and competition as well as value into individual insurance.
But just the early phases of Obamacare – the requirement that insurance companies spend 80 percent of the premium of actual health care rather than profits, salaries and marketing as well as for preventive and wellness care without copays, and the ability of young people to stay on their parents’ policy until age 26 – has already bent the cost curve, which had been inexorably rising at triple the CPI for decades.
What no one has said, but Rodberg is acutely aware of, is that the private insurance companies still control allocation of health care.
Rodberg knows first-hand. He didn’t relay this anecdote to Reach Out America, but it is in the testimony he gave in 2007 to the Hearing on the Partnership for Coverage before the Department of Health and Department of Insurance (Nov. 2, 2007).
He told the story of his wife, Joanne Lukomnik, who served as medical director for several community health centers in the New York area and was a consultant on primary care to a number of State and Federal agencies. In 1994 she was diagnosed with multiple myeloma, a cancer of the bone marrow. Doctors recommended she have an autologous stem cell transplant.
“Our insurance company turned it down, claiming it was ‘experimental.’ “ even though Joanne showed that this was a well-established procedure that had been used extensively and successfully at centers throughout the United States and France.
“She sent this to the insurance company, whose medical director called her a few days later. He said that, actually, he didn’t know anything about myeloma and just routinely signed the denial letters. He would reverse the denial.
“But it was too late. The transplant had been delayed by the denials and appeals, and she died before it could take place, leaving two teenage children and an angry husband. I had witnessed at a personal level what I had previously understood only theoretically.
“For-profit health insurance is a corrupt and conflicted enterprise. Their ads say they really care about our health but, as Milton Friedman told them and us, their job is to make money for their shareholders; they are not to be led astray by the claims of social responsibility. Somehow, in the last several decades, we have turned medical decisions over to these profit-making companies, whose interest is in saving money by denying care, not in preserving life.”
Nothing in that basic paradigm of health care provided under profit-making structure changes under Obamacare, with the exception that the level of profit in the insurance premium (not cost) is now capped. If true “free-market” supply-demand system would operate, a hospital could say, “What is it worth for you to save the life of your child? One million dollars? Two million?” (The insurance company negotiates what it will pay for the operation; you sign a document with the doctor that says you will be liable for the rest.)
But Obamacare preserves the for-profit enterprises, from the top of the food chain to the bottom. And they still have the power to refuse coverage for what they deem “experimental” (a best practices panel, which right-wingers have dubbed “death panels” would have helped, not hindered, especially if health consumers could have a place to apply to overturn a rejection); also, they still get to negotiate repayments schedules which can cause doctors to refuse to drop accepting insurance companies or leave their practice altogether.
“No other country allowed the so-called free market to control health care costs,” Rodberg says. “They understand in a way that we are taught not to understand, that patients are in no position to bargain over prices or comparison shop. When they need care, they need care, and you want a doctor that cares about you.”
New York Times this week was the latest to examine the outrageous and unequal prices charged by hospitals:
“California Pacific Medical Center’s 400-page chargemaster for this year contains some eye-popping figures: from $32,901 for an x-ray study of the heart’s arteries to $25,646.88 for gall bladder removal (doctor’s fees not included) to $5,510 for a simple vaginal delivery (not including $731 for each hour of labor, or $137 for each bag of IV fluid). Even basic supplies or services carry huge markups: $20 for a codeine pill (50 cents at Rite-Aid or Walgreens), $543 for a breast-pump kit ($25 online), $4,495 for a CT scan of the abdomen (about $400 at an outpatient facility nearby). Plenty of other hospitals set similar prices,” Elizabeth Rosenthal wrote in “As Hospital Prices Soar, a Stitch Tops $500,” (Dec. 2)
This prompted a response from Rich Umbdenstock, President and Chief Executive, American Hospital Association, Washington DC (an organization that spends $20 million a year on lobbying):
“Paying the wages and benefits of the highly qualified nurses, physicians, caregivers and other staff required to be on hand around the clock consumes about two-thirds of hospital budgets. This standby capacity is not explicitly funded and must be built into the charges for covered items, but patients and communities depend on this capacity and expect it when needed.
“No other institution operates under a system in which it receives less than the cost of providing services to the majority of its customers — Medicare and Medicaid patients — and routinely provides emergency and other services to patients who cannot pay. And few operate under a regulatory burden that comes close to that of hospitals — a burden that is increasing and adds greatly to the cost of providing services. To keep their doors open, hospitals must account for these factors and many more in their billing practices,” Umbdenstock wrote.
That seems a fair argument – doctors and nurses should be well compensated – but the story also prompted another letter writer to relate her experience, drawing the distinction between US health care (which contrary to the Rightwing Anti-Obamacarists is not the best in the world) and a universal coverage system:
“While on a recent visit to Berlin, I sustained a large gash on my leg while getting into a small bus. Bleeding profusely, I went to the nearest hospital’s emergency room… Not carrying German insurance, I was handed a bill, which listed in great detail all procedures. I was charged the equivalent of about $68. What would the same treatment in a New York hospital have cost?”
“You commonly hear ‘American’s don’t have enough skin the game’ – people think others are getting free ride,” Rodberg says. “But we’re spending more than any other country, 41% spend $1000 or more out of pocket, almost twice the rate of next highest, Australia.”
“We are unique in two ways. Not only do we not have universal coverage but we spend 60% more than the next most expensive system (Switzerland), twice as much as the average advanced industrial country. We spend too much and get too little.”
Theoretically – and contrary to the bleak picture Rodberg painted for Reach Out – some of this price issue will be moderated because there will be less “uncompensated care” – if people all have access to health insurance, fewer will be using emergency rooms as their primary care and fewer procedures will be “uncompensated” and therefore heaped onto the cost of everyone else ($1000 in every premium, and clearly, in the rest of the prices we are charged for services).
One could also make the argument that Obamacare will help reduce overall spending for health care because of the focus on prevention and wellness (free annual checkups and major diagnostic tests) – which will help prevent illness as well as catch ailments early when they can be treated more effectively and cheaply.
Still, Rodberg argues that Obamacare will not stop the increase in health care as a percentage of GDP. He points out that the national health expenditure as percent of GDP is projected to rise from 17.8% of the economy in 2009 to 21% in 2019.
Other countries that actually have universal health care have seen their percentage of health expenditure consistently stay below 10% of their economy, in the 8-9% range for the past 15 years.
“If we keep going this way, health care costs keep rising, taking larger and larger share of money we would like to spend on living rather than doctors. At some point, we have to do this in a rational way – like the rest of world has done it.”
But Rodberg goes further, puncturing the claim that Republicans make that Obamacare shifts the “burden” of health care for “others” onto taxpayers, makes the argument that taxpayers are already shouldering the biggest burden of health care expense. In essence, the argument is the same as for corporations like Walmart and McDonald’s who pay their workers so little money, they qualify for billions in federal services – food stamps and such (corporate welfare).
Today, half of Americans get insurance from employer-based private insurance, 169.7 million but represents only 34% of the dollars spent on health care (the government takes the lion’s share)
because they only [or rather mostly] cover the healthy ones, and government has to pay for sicker. The federal government also subsidizes private insurance by making it a business expense (tax breaks). The government already is spending more than half of all the health care costs.”
This makes sense because employers don’t hire sick people and if an employee gets too sick to work, they also lose employer-based insurance and the ability to pay for insurance if they can acquire it at all because of their pre-existing condition.
With Obamacare, he says, even more money will come from the public sector: 29% will come from private insurance (subsidized by federal taxes); 40% will be paid by the federal government; 12% by the state; 12% out of pocket and 7% from other private sources like charity.
So Rodberg makes the argument that we are already more than half way to universal health care, in the sense of government payments, but we do not have universal health care in terms of access or cost controls.
It didn’t have to be this way, Rodberg says.
In Obama’s words, he found a way to increase access to health care for the greatest number with the least disruption to the existing health care system. At the time, more and more employers were abandoning subsidized health benefits or requiring employees to pay so much, it was unaffordable, especially as the cost of health care continued to rise, averaging $16,000/year for a family; while 20,000 people a day were losing access to coverage because they lost their jobs altogether. That was the immediate crisis that Obama faced in 2009, while at the same time, seeing the growing share of health care to the GDP as draining the life out of economic recovery. But in trying to placate Republicans and the insurance industry’s Sen. Joe Lieberman, they made a “kludge.”
“ACA is a political Kludge – a clumsy, jury-rigged solution forming a distressing whole,” Rodberg says “The simple solution which would have been to put everybody on Medicare wasn’t politically possible, so Obama and Democrats went for a more complicated solution, invented by Republicans 20 years ago and passed in Massachusetts on a bipartisan basis.
“But why did this thing have to be so complicated in the first place?” Rodberg asks.
The Affordable Care Act is 2,700 pages. The Canadian Health Care act establishing a single-payer system is eight pages, he said.
“Imagine, now, a much simpler system in which the government just pays your major medical expenses… Such a system actually exists and is wildly popular and efficient: It’s called Medicare.”
Some Republicans are charging – absurdly – that the roll-out was an intentional disaster in order to push people out of their private insurance and force them into a situation where everyone will have government run, single-payer (that’s right up there with “death panels.”)
“Democrats are not that clever to have the Machiavellian scheme to have this kludge as a way of really getting single payer – I wish they were that smart,” Rodberg says.
And yet, Obamacare may well be to health care what “natural gas” is to climate change – a transition. Like natural gas, it benefits controlling interests in the economy. And like natural gas, it was the best that could be accomplished in this political environment.
There are those in Congress that are still pushing to for single payer- Congressman John Conyers has a bill, HR 676, to do just that: extend Medicare to cover everyone; offer comprehensive benefits; free choice of doctor and hospital; public agency processes and pays bills; pay for it through progressive taxes; spend no more than we are spending now.
Similarly, some states are working toward universal coverage – Vermont, for one. And there is health care reform legislation in NYS- Gottfried-Perkins New York Health bill which would provide for: universal comprehensive coverage – everybody in, nobody out; coordination of care by care manager; no copays or deductibles; paid for by graduated payroll tax and existing federal funds; covering everyone while spending less than we pay now).
In 2016, states will be able to get waiver under ACA in 2016 to do their own plan. That would be the Republicans’ chance to put up or shut up, since so far, they only have offered “repeal” based on their abhorrence of a federal “takeover” of health care without offering any alternatives.
In fact, if the private insurance industry knew what was good for it, it would support, not obstruct ACA (as it has with fraudulent letters that blame Obamacare for cancellation of junk policies).
Because now that the American people have had a taste of true health care reform, they are going to question the whole for-profit system.
