Obamacare Is On The Road To Success

A remarkable and rather unheralded development is quietly taking place regarding the Affordable Care Act (Obamacare) health overhaul.  Enrollments are surging now, particularly in the 14 states running their own exchanges.  The Buffalo News reports that the Empire State signed up 48,162 last week, about half of whom bought insurance on the exchange while the other half signed up for the expanded Medicaid eligibility.  Connecticut is on track and about 14% of the way to their enrollment goals for the March 31 deadline.

Covered California has signed up 59,000 for the private exchanges and added 72,000 to Medicaid.  The Golden State is adding another 2,000 people a day to its rolls.  Covered Oregon "cut its uninsured population by 10 percent in the first six weeks of enrollment."  The Los Angeles Times  reports rapidly accelerating momentum.  "California — which enrolled about 31,000 people in health plans last month — nearly doubled that in the first two weeks of this month."  "What we are seeing is incredible momentum," said Peter Lee, director of Covered California.

The effects of state cooperation have been important.  To give you an idea, Kentucky is the only southern venue in which the state government has supported the program.  5,586 Kentuckians have signed up for insurance there.  Meanwhile, 2,921, about half as many, have signed up in Texas, even though Texas has six times Kentucky's population. 

Nationwide,about 400,000 people have been added to Medicaid and about half that many have secured private insurance coverage through ACA.  Despite the rocky federal website roll out, as things continue to improve the country is rapidly reaching a tipping point.  Before long there will be a million people directly helped by Obamacare.  As the detractors have feared all along, once that happens they will never be able to get rid of it.  It will prove as politically impossible for them to repeal the program and take coverage away from people as it has been for them to repeal Social Security or Medicare.

What to Do About Contraceptive Coverage

One of the hot topics in the forefront of current public debate concerns the Affordable Health Care Act's requirement that contraception must be covered in health plans.  See the Department of Health and Human Services summary here.  While religious bodies that object to contraception are allowed to exempt their ministry employees from this coverage, the Obama Administration has ruled that the Act requiresthat employees not directly involved in the ministry of the body, such as employees of a church-owned hospital, must be covered.  In order to keep such religious bodies from having to pay premiums for services they do not agree with, health insurers have said they will be happy to include the coverage free.  Insurance companies have not made this offer out of charity; it's because paying for birth control pills is a lot cheaper than paying for prenatal care, delivery and health care for a child.  But this has not satisfied all the objectors.  Let's take a look at the positions.

Opponents see the mandate as an egregious intrusion of government control into the realm of religious free choice.  The U.S. Conference of Catholic Bishops, for example, decries the requirement on its website under the heading "unconscionable to require citizens to buy contraceptives against their will."  They and others see First Amendment ramifications that threaten religious liberty.  The Blunt Amendment (Senator Roy Blunt, R-Missouri) to the Health Care Act, which passed the House but was defeated in the Senate, would have allowed any employer to opt out of the mandate on religious, moral or other personally-held grounds.

Supporters see the mandate as providing needed services used by most women, and as a part of the larger issue of women's freedom to make their own decisions.  A survey by the Public Religion Research Institute covered in the Washington Post shows the majority of Americans support the mandate, with Catholics supporting it more strongly than the population as a whole.  The story points to other findings that 99% of all women and 98% of Catholic women have used artificial contraception at some point in their lives.

Since there are strongly-held principles in apparent conflict here, where should the balance of rights and interests be drawn?  It seems to me that the outline of a reasonable and just solution is clear, and it lies in personal choice.  To deny a widespread pharmaceutical practice used by virtually every American woman due to the objections of religious bodies smacks not of freedom of religion but of establishment of religion prohibited under the same First Amendment.  The statement of the bishops that anyone will be made to "buy contraceptives against their will" is completely wrong.  First, the employer will not be buying them.  Second, no woman is required to ask for or take them.  Only women who ask their doctor for a prescription for birth control pills will get one.  The idea that anyone will be forced to ingest birth control pills against her will is a complete invention and red herring.

In this way, the decision is where it belongs: with the patient.  Make the coverage available to all.  If anyone has a religious or any other objection, she may decline to ask for contraception.  But the decision should not be up to her employer, her preacher, her husband or any other person.  These may give advice, but as with any other medical decision in a free country, the choice is up to the patient.  Picture the shoe on the other foot: Imagine how it would go over if a man had to get permission from his boss in order to buy a condom.  If a boss is a Jehovah's Witness should he have the authority to keep any of his employees from getting a blood transfusion when they are bleeding to death?  If the boss is a Christian Scientist should he or she be able to deny employees antibiotics when they contract an infection because the boss doesn't believe in them, regardless of what the sufferer believes?  Under what principle do we give a person's employer the power to make life and death medical decisions, rather than letting people choose for themselves?  When viewed in this light the issue clarifies itself.  The mandate to cover everyone and let them decide their own medical needs for themselves is better from a public health perspective and more in accord with American concepts of personal liberty, including religious liberty.        

Thoughts on Health Care

Yesterday President Obama and the representatives of six major health industry interests stood together at the White House and proclaimed their determination to rein in the industry's rising costs and produce reform this year. In terms of tone and a photo op, it was big news. As a matter of substance, it left more than a little to be desired.

Voluntary targets; where have we heard that before? The conventional wisdom is that the HMOs are making nice in order to avoid stringent regulation. Reducing the growth rate of increase by 1.5%, even if achieved, would leave that rate of increase above inflation, and thus still unsustainable.

For a new system to be credible it must first be universal. People cannot be left without access to coverage because they are not well and thus unprofitable for someone to insure. Three things are needed in whatever plan emerges. One is that there must be a public component in the mix. Another is that outcomes rather than just treatments must be incentivized. Finally, people must have a choice of physicians.

From his days as a candidate Obama spoke of a system in which people could join a public-sponsored plan or keep private insurance. Powerful interests will try to scuttle the public provision. They must be resisted if the new system is to accomplish much. On the surface one would think their belief in the innate superiority of privatism should make them welcome and even relish competition with a government-paid program. The fact they are so afraid of it and will try to kill it is clear evidence of their belief in the contrary. They know a system like medicare will save consumers, be they the public as an entity, individuals or business. Once in place such a system will likely gain the majority of the national business. If such is not included in the overall plan it will be clear evidence that business as usual has won the day.

Enormous improvements in cost and public health can be achieved by incentivizing outcomes rather than tests and treatments. For instance, British doctors get a bonus when a patient stops smoking. There could be similar incentives for when patients lower their cholesterol or reach or maintain a healthy weight for their height. These are the kinds of intelligent ideas that will cost a little up front but save much larger sums down the road in treatments for serious diseases and conditions.

These, then, will be the hallmarks of a plan that brings America into the modern world. No first-world nation should have one-sixth of its citizens uncovered for medical care or have medical expenses as its second leading cause of bankruptcy. Former Vermont Governor Howard Dean's organization, Democracy for America, is leading the campaign to make sure a public component is included in the new health care mix. To register your support click here.

Another Unnecessary Death

I talked to a woman today who's losing her daughter to breast cancer. We'll soon have another preventable death and another set of motherless kids.

Let's call the daughter Holly. Holly has four children. Holly got divorced. Holly had no health insurance. So when she felt a lump in her breast, Holly didn't go to the doctor. There would have been the visit, then referral to a specialist, then all sorts of tests. That kind of stuff is expensive. She'd had a lump that wasn't malignant before. Maybe she would get lucky again, she hoped. Maybe she could save some money she and the kinds really needed.

But maybe didn't happen this time. When Holly's mother finally found out she told her to go; she would pay for it. By then several months had gone by. The news was bad. The cancer is in both breasts and the lymph system. Holly was told she had only weeks to live, no more than a month.

But Holly is a fighter. She's a former top high school athlete and still has a competitive streak. Her mother is going to borrow money for a desperate operation. They're going to remove both breasts, a lot of skin and many lymph nodes. Then she'll have massive radiation. There will be a lot of sickness and excruciating rehab. The prognosis? This will probably delay her death by two or three years. As extensively as the cancer has spread there's almost no hope of getting it all. It's probably in her thoracic organs. But there might be a 1% chance of longer-term survival. And a couple of more years for the kids to have a mother will be good, too. After all, the youngest is only three.

On a national news show yesterday I saw a wealthy attorney whining about the Obama proposal to let income taxes for those earning at least $250,000 a year return to their pre-Bush levels, going up 4% to fund a $600+ billion reserve to get a national health insurance program off the ground. He complained it would "destroy my American dream." Cry me a river, bub. Take one more DUI case a year if you're so down about paying an average extra $1,100 in taxes after deductions out of your $300,000 income. What about Holly's American dream? What about her kids? What about the 50 million (and rising) other Americans in the same boat? How many more thousands must die for no good reason? I often wonder what planet people like that attorney come from.