A Chronic Disease

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A Chronic Disease
Obamacare won’t go away on its own By Ramesh Ponnuru
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Conservatives and Republicans in Washington — activists, strategists, politicians — are increasingly embracing a theory about Obamacare: It’s going to collapse of its own weight, and its failure could yield a sharp right turn in the 2014 and 2016 elections. That theory is probably wrong, and dangerously so. To be rid of Obamacare, Republicans will have to do more than just wait for it to go away — and more than they have done so far.

You can see why the theory has caught on. The early implementation of Obamacare is not going well, with every week bringing fresh news embarrassing to the law’s proponents: Insurers are raising premiums, sometimes dramatically; the administration has had to announce that it will miss statutory deadlines; companies are planning to scale back coverage or even drop it completely. Senator Max Baucus, the Montana Democrat who did as much to shape the law as any other person, said that implementation could be a “train wreck” and then said he would not run for reelection next year. And there are reasons for thinking that the law is too badly conceived ever to work well.

The law takes an inefficient model of health financing — in which insurance is used to prepay routine and predictable medical expenses — and extends it to more people while making it more inefficient still. It assumes, unrealistically and against precedent, that government-backed experts can drive efficiency in health markets. It ignores how people respond to incentives: by performing fewer services when price controls are imposed, for example. These flaws are central rather than incidental to the law. They follow from its misdiagnosis of what ails American health care as, essentially, markets that are too free. Eliminating these flaws would require rewriting the entire law, which is to say replacing it.

President Obama, in a press conference on April 30, conceded that there would be some “bumps” on the road to the law’s destination. He suggested, however, that the only people affected by these bumps would be those who lack insurance now but will have it once the law takes full effect. “For the 85 to 90 percent of Americans who already have health insurance, this thing has already happened. And their only impact is that their insurance is stronger, better, more secure than it was before. Full stop. That’s it. They don’t have to worry about anything else. The implementation issues come in for those who don’t have health insurance.”

Those remarks reflect a disturbing disconnection from reality, one that probably comes from reading too many liberal bloggers. People who have insurance now do indeed have to worry that their premiums will go up, their coverage will be dropped or reduced, and medical innovations that could help them will slow down. And the law will leave many people who lack health insurance without it: The Congressional Budget Office estimates that even after all the law’s taxes, spending, and regulation are implemented, 30 million people in our country will not have health insurance.

Because the law is unlikely to work, because it cannot be meaningfully improved while keeping its basic design, and because it remains unpopular, Republicans would be mad to acquiesce to it. (For a more extended version of this argument, see my article with Yuval Levin, “Repeal, Replace, Still,” in the April 8 issue of NR.) They should not worry that in five or six years almost everyone will see the law as a success. It is likely to be a failure by any reasonable measure.

The reasons for thinking the law will fail are not, however, reasons for thinking it will self-destruct in short order, or harmlessly. Critics have, for example, raised the possibility that the law will cause a “death spiral” in insurance markets. The law allows people to buy insurance without prejudice once they are sick. In one scenario, many people will therefore stop buying health insurance when they are well. The law will make them pay a penalty for going without insurance, but the penalty will be much lower than the insurance premiums they will be avoiding. The fewer healthy people are in the insurance pool, the higher premiums will have to go. And the higher premiums go, the more sense it will make for healthy people to drop their coverage.

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Expanding Medicaid coverage is not a cure-all

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OpinionsExpanding Medicaid coverage is not a cure-all By Roberta Capp, Roberta CappJun 13, 2013 11:52 PM EDT

The Washington Post

Roberta Capp is a Robert Wood Johnson clinical scholar fellow at Yale University, where she practices emergency medicine and is researching health care delivery for patients with Medicaid and Medicare insurance.

The debate over “Obamacare” has focused largely on the number of uninsured Americans and how the regulations will be implemented. Not enough attention is being paid to the difficulties our health-care system imposes on those with Medicaid insurance, which is being extended to millions who lack coverage.

Frequently, people blame patients for using emergency departments “inappropriately.” But some Medicaid patients do everything they can to see a doctor, to no avail, and must resort to emergency department visits. My own experience has been instructive.

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Tom Toles on health care:?A collection of cartoons on the debate.

One Monday a few months ago, the waiting room of the emergency department (ED) where I work had 30 patients, some of whom had waited 12 hours to be seen. My first patient was a woman with chest pain. She has Medicaid insurance. Her medical problems include diabetes, previous heart attacks, asthma and acid reflux. I ordered an electrocardiogram and saw from her file that she had been evaluated in the ED for chest pain 14 times in the past year and hospitalized on seven of those occasions. After reading her previous diagnostic tests and treatments, I was confident that her chest pain was not caused by a heart or lung problem. I was also curious about how her care was being coordinated.

The first time this woman had chest pain, she said, she called our hospital’s primary-care clinic, where she had seen a different doctor at each previous appointment. After holding for more than 30 minutes, she hung up and went to the emergency department. That visit resulted in a hospital admission for a heart stress test, the results of which were normal. But this woman continued to experience pain. She later saw a doctor at our primary-care clinic who prescribed an acid-reflux medication and told her to return to the ED if she had more pain.

This woman prefers to see a ­primary-care doctor, she told me, which is why she would call the clinic when she had pain. But often she was either unable to get an appointment right away or couldn’t get a person on the phone. When she did reach someone, once she said “chest pain,” she was almost always told to call 911 immediately and go to the ED.

The patient’s records showed that in the past year she had had two cardiac stress tests, one coronary catheterization procedure and two CT scans of her chest, all of which were normal. Simply put, she received the best care possible — and doctors assessing her were reassured that she did not have heart disease or a clot in her lungs. But she also underwent duplicate testing, which increased her costs without providing additional benefits, exposed her to more radiation and raised the potential for false-positive test results.

When this patient was able to get an appointment quickly, she then had to arrange transportation. Medicaid will pay for taxi service, she told me, but she has to call at least three days ahead to schedule the ride. Ultimately, she told me, she has concluded that “the only way to see a doctor soon enough is to call an ambulance” and go to the ED.

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