Our roundtable participants
Gene Krebs, former state representative from Preble County and chair of the Ohio Consumers’ Counsel Governing Board.
Dr. Shawn Cassiman, associate professor of sociology, University of Dayton.
Dr. Ryan Simon, a Dayton physician.
Moderators: Michael Williams, Ron Rollins
The Affordable Care Act, aka Obamacare, has been very much in the news this fall as consumers were able to start learning about health insurance exchanges for the first time this month, as they found the government website promoting them was less than perfect, and as the rancorous political debate over the program reared its head in Congress yet again. We wanted to talk with some thoughtful local observers, however, about some of the law’s possible long-term effects — both those that might have been predictable and those that might be accidental. The conversation we had with a panel of three experts — a doctor, a professor and a government policy pro — was far-ranging and intriguing. Today, we present an edited, condensed version of the discussion.
Moderator: So, there has been a lot of talk about the immediate impact and the politics surrounding the Affordable Care Act, but it’s such a large public policy change that it’s bound to have unintended consequences. What do you think some of those might be, looking down the road?
Gene Krebs: I'd say, from a quarter century of drafting legislation, that it's not unlike what happens in medicine, that you give a prescription and there are definite side effects, and they depend on the person, their diet, their health, their heritage. It's the same with public policy. It's like an overlay of chaos theory. The Affordable Care Act, because of its complexity, has me very worried and concerned, as we move through it, of all the possible unintended side effects. It's a classic case of complex legislation that sounds good to a lot of the advocates for it, but there's just a lot to it. For one thing, we've got a supply-side economy and a demand-side government, and the ACA attempts to bridge the two.
Shawn Cassiman: Actually, I think the idea of the complexity is just being used by the people who oppose the law to try to scare people off of it. It's what the Koch brothers have been trying, even though it's all modeled after Romneycare in Massachusetts. Really, though, the decision on a policy for health care is no more complex than buying a car. And, of course, there will be unintended consequences.
Ryan Simon: One thing I've observed is that the ACA itself is more complex than it had to be. If you ignore a problem long enough and keep putting off fixing it, then the more costly and complex the solution becomes. You could patch your roof when it needs it but, if you don't, it'll fall in and cost a lot for a new roof. We've acknowledged these problems for a long time, and have always put the solutions off for later. We don't know if the proposed solution will end up more simple, or more costly, than what we have now.
Krebs: It's myth that liberal/progressives love to tell that this is just Romneycare 2. For one thing, Romney's plan had massive bipartisan support. The ACA violated one of my key rules of good political legislation — which is not necessarily the same thing as good policy legislation — and that's what I call the 85-50-and-1 rule. That's when a law is passed by 85 percent of the majority caucus in the chamber, 50 percent of the minority caucus, and then it's signed by the governor or president. That didn't happen here because, unfortunately, the minority caucus was told by Obama that elections have consequences, and get over it.
Cassiman: Wait a minute — are you actually saying the tea party has nothing to do with what's going on right now? Where they're shouting that they want blood unless they get what they want?
Moderator: Actually, let’s not relitigate how Obamacare was created and got to this point. What do you think the ACA looks like in, say, 25 years?
Cassiman: It'll turn out to be just like with Medicare, same thing. People who were opposed to it said it was socialism, and horrible, but it's turned out to be one of the best programs in the country. A lot of progressives think the ACA didn't go far enough. We have people dying for a lack of health care.
Simon: Well, for it to work well, the consumer has to know what is being sold to them, and most insurance policies aren't written at an understandable level. We know from past studies that when seniors enrolled for Medicare Advantage, only 17 percent ended up in plans that were really beneficial to them. So, from the start, this will be confusing.
Cassiman: Well, there were supposed to be navigators who could help people through it, and they were blocked in Ohio and some other states.
Simon: I just know that after I have to fight with insurance companies, I feel like I need a shower.
Krebs: What about systems like they have in Costa Rica or Panama, where you can fly and get your hip done for a quarter of what it costs here? I've heard of people doing that, and I haven't heard any substandard care issues there.
Cassiman: It depends on the hospital, I think.
Simon: That's right. There's probably a small minority of people who could do medical tourism, as it's called, but you'd still have to shell out thousands of dollars. You have to travel, for one thing. You may have good outcomes, but there's no one forcing a hospital in India to tell the truth, whereas here Medicare will watch the hospital. But that doesn't keep our costs down; an artificial hip is a $450 chunk of metal that we'll charge $40,000 for in this country.
Cassiman: Isn't the hope that increased access will change that? That with more people covered, that will drive prices down.
Simon: If you spread the risk base, then the total cost will be spread out more evenly. We aren't doing that now. There are a lot of inequalities not being addressed by the market system, because the market has no incentives to fix them.
Krebs: Back to your question, about what the future holds? It would be profoundly arrogant for anyone on the left or on the right to pretend they know. It's rare that the drafters of any legislation can accurately predict what its impact will actually be. And until we get some better math models for this one, we won't know.
Simon: Well, look back 40 years ago — in the mid-'70s we had CAT scans, but they were basically worthless, MRIs were merely theoretical. Now you can build a 3D image of all the tissues in a patient's body. I'm not saying technology is the answer to all our problems, but it's really hard to predict 40 years from now.
Krebs: I've heard the Affordable Care Act described as an "ugly patch on an ugly system." We're No. 1 in the cost of health care in the world, and No. 37 in our level of care, our quality of outcome. So we're high in cost with relatively mediocre results. I wonder where in the system are the pressure points where we can start to apply pressure and contain costs, and if the ACA will change any of that.
Cassiman: Well, the variable in other developed countries is that most of them have universal health coverage. Like I said, Obamacare didn't go far enough.
Simon: They have some form of it. Different systems in different places, and most are patchwork. I did my third year in medical school in Ireland, and they have a national health service that started out for women and children, then for older persons, then it evolved to cover everybody. It's not an ideal system, there's always some friction and loss — but it covers everybody, so the risk is spread out. Hospitals there are owned by the government and doctors work for a government salary, but can be paid for other things. You can buy additional health insurance as a citizen and offer your doctor that additional incentive for him or her to do additional work. There are other systems, of course.
The Swiss system is a private-public partnership with non-profit insurance providers that works pretty well. We’re unique because we pay more and more for less-good outcomes, and we don’t even cover a lot of people, and they fall through the cracks. As far as curbing costs? I don’t know how successful that will be. One way would be to expand access to primary care, which will keep people from going to emergency rooms, which are very expensive. Primary care doctors are among the lowest paid in the profession. If you increase pay for primary care doctors, you’ll presumably get more of them, and better access to them for more people would reduce overall costs, but that would be savings over decades.
Moderator: What other Affordable Care Act ramifications do you foresee?
Simon: The ACA calls for a lot of quality monitoring and data mining. That could also have impact on costs and on improving treatments that could be positive.
Krebs: We're used to employee-structured health insurance as part of our overall system, and I anticipate in 20 years for that not to be in existence.
Moderator: Could that affect the idea of what constitutes full-time employment?
Simon: That's an interesting concept. We settled as a society on this 40-hour work week, but studies show that productivity kind of peaks around 28 to 30 hours a week. Maybe that would be a good thing.
Cassiman: The United States is one of the few places with employee-based benefits of the type we're used to, and that's been changing for a long time. It's likely to continue changing. And our employment habits are changing, too — we move often now from job to job, so it's possible to see insurance changing so that it's not specific to your job, but moves with you.
Moderator: Would that be good for business?
Simon: I think it would be. Look at how much of the cost of a GM car is tied to paying health benefits, as opposed to a car made in Japan. It's something like $1,400 compared to $400 or $500. And Japan is a place where they have better health outcomes, spread-out cost and no double-digit increases in costs. I think insurance portability would be a good thing, if you could divide jobs and health care.
Krebs: I like the ideas of health care savings accounts. It's an idea advanced by (retired neurosurgeon) Ben Carson where, when you're born, you get a Social Security number and a personal coverage account. Everyone has one that the government puts money into, and the consumer manages it for their care. It would address a lot of these issues.
Cassiman: Why not just expand Medicare for everybody? That would eliminate the middle man.
Simon: Medicare is really quite a remarkable program that has been successful on a lot of fronts. It has very low overhead, compared to private insurance companies, so more dollars are actually spent on delivering health care. And it covers a population that nobody wants to cover, seniors. You know, every year Bernie Sanders proposes just expanding Medicare to everyone — it's a simple, six-page bill, not like the 1,500 or so pages for Obamacare. And it never gets traction.
Moderator: So, back to the politics of it all for a moment. Does the outcome of Obamacare, its success of failure, give one party an advantage over the other?
Cassiman: Why do you think the Republicans are trying to hard to make it fail? They've turned it into a political volleyball, and they really want it to fail. They've bombed it every way they can. You've seen some of those ads they're running to damage it. It's unconscionable.
Simon: I don't see it as a game changer for either party. When I've done town halls on this, I've had seniors saying things like, "Keep your government hands out of my Medicare." So the people who may be hurt or who may benefit from the Affordable Care Act may not even give credit where it's due. We're not rational beings when it comes to politics, just as we aren't when it comes to religion. Our brains allow cognitive dissonance.
Krebs: I need to refute the idea that all Republicans are salivating to drive a knife into the ACA. There are many, like Charles Krauthammer, who is very conservative, who say let it go forward and die of its own contradictions and then let's pick up the pieces. Of course, a lot of people will suffer if that happens.
Simon: You know, it would have been nice to have had an actual discussion about where we are as a society on this subject — on how we feel as a society about whether people should be vulnerable when they're hurt or sick, and how we should change that problem. Instead, we just had this massive campaign of disinformation, preying on people's fears and irrationalities. I would have been proud of our country if we had avoided that, but we didn't.
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