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Experts address candidates’ health care plans

Kristen Durbin | Friday, November 2, 2012

Although the Supreme Court upheld the constitutionality of the Affordable Care Act (ACA) this summer, the debate over the future of American health care continues to be a major issue, especially as the outcome of Tuesday’s presidential election could potentially change the trajectory set by the ACA.

If President Barack Obama wins reelection, he will focus on the implementation of fundamental elements of the ACA beginning in 2014, including affordable insurance exchanges and a significant expansion of Medicaid, according to Dr. Aaron Carroll, the director of the Center for Health Policy and Professionalism Research.

But Jim Capretta, a fellow at the Ethics and Public Policy Center and author of “Why Obamacare is Wrong for America,” said the ACA will lead the country down the road to ineffective, expensive health care reform due to a large-scale centralization of power by the federal government, a move Republican candidate Gov. Mitt Romney opposes.

“It’s indisputable that the main aim of the ACA is to use the federal government’s regulatory, taxing and spending authority to reshape the health care system and move massive amounts of political power out of the hands of employers and private citizens and states to the federal government,” he said. “The government is now in the driver’s seat of the health care system … where it can direct what people do in terms of health care.”

Capretta said he thinks that shift in power could prove treacherous in its future consequences.

“Anyone who’s worked around the political process knows that things like this have a certain inevitable trajectory. First of all, bureaucracies never cede power,” he said. “Once power is moved to the federal government, it will only expand over time.

“The federal government is a one-size-fits-all structure that doesn’t have the authority to be nimble in managing a big enterprise like the health care system, and it will dictate terms … that don’t recognize the diverse nature of the country and very different views on quality health care.”

Rather than dictating every health care decision Americans make, Carroll said the ACA sets a standard of universal coverage and gives people options to expand that coverage if desired.

“The idea that the federal government is taking over everything is a bit overblown in the sense that they’re just setting baselines. They’re absolutely not saying, ‘You can’t get this or that coverage.’ They’re just saying, ‘You can’t have less coverage than this,’” Carroll said. “Individual states can do as much as they like above that baseline.”

In terms of state power in health care reform, Capretta said decentralizing power from the federal government to state governments, as Romney has proposed, would promote freedom of choice among consumers and help strengthen the market for private health care.

“Romney wants to push the health care system towards a market-driven approach instead of centralizing power at the federal level and do so in a way where the federal and state governments oversee the marketplace, ensure that it operates fairly on behalf of consumers and then try to empower people to make choices for themselves,” he said.

More specifically, the issue of entitlement reform has come into heavy questioning in the context of increased government influence on the health care system.

“Throughout the campaign, Romney has signaled that he will take entitlement reform very seriously as president,” Capretta said. “Obama has signaled that he doesn’t want to make structural changes to either of the major health entitlement programs, so there’s a big difference between the two candidates in this regard.”

But Carroll said Obama actually prioritized Medicare and Medicaid reform in the ACA.

Although Medicare often takes the national spotlight in presidential and other political debates, Carroll said the differences in the two candidates’ policies on Medicaid are actually “much sharper,” with Obama and the ACA stipulating a “massive expansion” of Medicaid to include 16 million additional people beginning in 2014 and Romney proposing to change Medicaid into a block grant program that provides funds to states to pay for care.

“[The block grant program] saves money by severely restricting how quickly the size of the block grant goes up. A low cap will be set, so the amount of money spent on Medicaid under Romney will be much lower than otherwise predicted,” Carroll said. “Unless there’s some magic, that means there will have to be fewer people covered or the benefits will be far less.”

Critics of the ACA often point to the Medicaid expansion as a huge drain on government and taxpayer resources, but Carroll said the program’s insurance plans cost less per person than providing subsidies to people to buy private insurance.

“If it was cheaper to give people subsidies, that’s what the ACA would have done because no one wants to spend more than they need to on care,” he said. “The reason we have Medicaid is because certain groups of people can’t afford private insurance.”

Contrary to the common perception of Medicaid beneficiaries as people who choose not to work, Carroll said the program mostly covers the most vulnerable Americans who are generally unable to work: children, pregnant women, the elderly, the blind and the disabled.

“It’s not as if they’re people who should be working and are not. They’re people who can’t work for some reason, so insurance is incredibly expensive for them,” he said. “The amount of Medicaid funds spent on the blind and the disabled is huge, much higher than what’s spent on kids, and private insurance would cost a fortune because anyone rating them would see that their care is vastly more expensive than the average person.”

Thus, considering Medicaid funding cuts or a repeal of the program’s expansion under the ACA brings up a fundamental ethical question, Carroll said.

“If you’re thinking about cutting Medicaid severely, you have to ask yourself which of those groups you think should be working harder,” he said. “Which should be getting off their butts and earning more money and pulling themselves up by their bootstraps?”

Although critics may view Obamacare and its call for expanded coverage as a violation of individual decision-making in health care, Carroll said the problems in the American health care system are not individualized.

“It’s logically consistent to take the libertarian view and say everybody makes individual choices about health care,” Carroll said. “But the problem arises when people get sick, go to the emergency room and are charged for care they can’t afford. When people can’t pay, the rest of society has to pick up the bill. It’s not individualized, and eventually we’re all responsible for the millions of dollars in uncompensated care that gets spread out among people.”

More than shared responsibility, Capretta said the American health care system needs an injection of free-market sensibility to operate more efficiently.

“What’s needed most in health care is the discipline that comes from a functioning marketplace, a point Romney made in the first debate,” Capretta said. “That doesn’t mean the discipline from market forces can’t also be coupled with a proposal that provides relatively stable and relatively universal insurance.”

Based on the example of uncompensated care being paid for by taxpayers, Carroll said he is not convinced of the power of free-market economics to solve the country’s health care reform issues.

“You can let the free market try to take care of [health care reform], but it doesn’t work, and the same argument can be made for states,” Carroll said. “States have been free to act on health care reform – Massachusetts did several years ago – but the vast majority of states are not controlling this problem, so when the problem isn’t controlled, the public has to pick up the bill, and that’s when government often steps in.”

On both sides of the political spectrum, Carroll said, the power of the free market and the private insurance system has certain limitations.

“Because [Americans] will eventually take care of [uncompensated care], the next-best solution is to get people into the government health system because it’s not being controlled by market forces,” he said. “Even the right will acknowledge that the government should step in when the free market and private insurance can’t or won’t get the job done.”

Romney has come under fire for not specifying what he would do after threatening to repeal the entire ACA if elected, but Capretta said the lack of a detailed plan creates flexibility.

“Obviously, Romney’s plan is more of a vision than a detailed legislative proposal at this point, and I don’t discount the notion that a lot of details are being left out. But I think his broad vision is relatively clear,” he said. “His framework leaves lots of room for some details to be filled in later.”

But Carroll said the alternative to the ACA might not be as perfect as Romney may consider his theory to be.

“It’s not as if you have the choice between the ACA and some awesome free market utopia,” he said. “It’s the ACA or what we had before, which wasn’t working and hasn’t been working for a long time.”