OEDEL: Compromise on Obamacare

September 29, 2013 

President Obama’s initial insight about the need for health care reform was right. As if to say that things aren’t working well health-wise for our low-income citizens, many of them in effect have been conducting a longstanding mass sit-in at emergency rooms nationwide, at huge costs to all. They’re implicitly protesting that we don’t offer primary care even at Chinese levels.

China has more than four times as many people as the U.S., including a huge population of obviously poor people who make many of America’s poor look like relative princelings. So why do the Chinese have life expectancies of about 76 years, nearly rivaling American life expectancies of about 79, when the Chinese spend on health care a much smaller share of their smaller GDP, 4.5 percent compared with about 18 percent in the U.S.?

In the poor hutongs of China’s cities, primary care workers appear in the streets with vaccines and various medical services for free or low-cost. Nothing fancy, but efficient and, overall, apparently effective.

In contrast, Obama’s administration continues stubbornly to emphasize dramatic expansion of Medicaid despite it being a dysfunctional mess, and Obamacare’s original Medicaid mandate having been found unconstitutional.

And now the administration is about to implement Obamacare’s constitutionally edgy project of “encouraging” low-income citizens to buy private insurance, prodded by tax penalties, hard-sell ad campaigns and paid “navigators.” That probably won’t work either.

People with low incomes are often skeptical of private insurance and its increasingly daunting co-pays, preferring when pressed to keep the rent paid, food plentiful and television on. They know the value of a dollar better than most, and that medical prices are wildly inflated.

They aren’t well situated to fight through the opaque insurance payment morass, or to coordinate different tentacles of the medical beast. Many of them will not get insurance, and many who get it won’t use it.

We’d serve the uninsured better by expanding free clinics and community health centers. Ironically, they’re also acknowledged in Obamacare, but most of Obamacare’s funding will go instead to subsidizing insurance and expanding Medicaid. In Middle Georgia, we have a solid community health center, First Choice Primary Care. We need more like it, not bigger profits for insurers.

Obamacare also endorses an innovative model for provider reimbursement. “Accountable Care Organizations” are identified in Obamacare as promising vehicles for achieving improvements in wellness. Instead of getting paid to churn out medical procedures ad infinitum, ACOs are paid per capita with embedded incentives for their covered populations to achieve better health outcomes. Locally, Dr. Sharian Sedghi is spearheading a new one, Georgia Physicians for Accountable Care. It’s a concept worth exploring.

Big improvements to affordability could also be made by insisting on transparent pricing and outlawing price discrimination by providers because of a patient’s insurer. We need a more rational medical marketplace, not more pricing gamesmanship.

As for the priciest, most innovative treatments, we all need to accept that not everyone can get them. Therefore, rationing is necessary. Private insurance markets and missionaries are in better positions to do that, not politicians and bureaucrats. After testing which of the expensive, rationed approaches work best, we could then roll out the best to the rest at a more cost-effective scale.

Some health care zones, like end-of-life care, cry out for radical rethinking -- but not by bureaucrats. We need to empower doctors and patient advocates to take charge of what has become an inhumane, shockingly costly form of torture.

Reform is conceivable, but the president remains obsessed with subsidizing insurance and dramatically expanding Medicaid without changing it. Those projects obstruct reform. The president recently dismissed Obamacare criticism as veiled personal animus. Opponents, he said, just “want to mess with me.” But he’s missing the merits of the critique.

Before insurance subsidies and Medicaid expansion fail to achieve the goals of better health at more affordable cost, the president might wisely compromise by redirecting the focus so more effective approaches can see the light -- some of them right there in Obamacare itself.

David Oedel served as counsel to Georgia in its partly successful challenge with 25 other states to the constitutionality of Obamacare.

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