Jim Paladino: The politics of health care
Published: Sunday, February 24, 2013 at 6:01 a.m.
Last Modified: Friday, February 22, 2013 at 10:54 p.m.
Politics as usual is shaping reform of the American health-care system.
Republicans hate the specter of Big Brother forcing Americans to buy health insurance, the so-called individual mandate, preferring that Americans retain the right to "just say no" to health insurance. Democrats, who never saw a problem they could not afford to solve, scream at the injustice of 32 million Americans suffering from poor health partly because they do not have health insurance. This political battle pits the evils of Big Brother against the benefits of the Nanny State.
Unable to repeal the Affordable Care Act, also called Obamacare, Republicans challenged its constitutionality. The paradoxical Supreme Court decision made both parties squint their eyes, scratch their heads, and ask, "Really?" According to Paul Starr, Princeton professor of sociology and public affairs, the ruling admits that under the Commerce Clause, government cannot mandate a commercial enterprise like health insurance; however, according to this Supreme Court, Congress can force individuals to buy health insurance because this unique mandate is a tax that Congress has a right to levy.
This gave Republicans ammunition to label Democrats as tax-and-spend liberals. It forced Democrats to explain how taxing the wealthy, employer fines and excise taxes on medical devices are not taxes, assuming that Democrats agree with the majority opinion. The Supreme Court further ruled that states could not be forced to expand Medicaid. This gave Republicans, states' right champions, cause for joy, but placed financial burdens on Obama to pay for Medicaid expansion.
Following the money sharpens the political divide in the battle to provide affordable health care to all Americans against the affordability of mandatory health insurance. Republicans espouse free-market solutions, believing that competition keeps costs down and government intervention stifles competition. But it may be difficult to explain why competitive markets never contained prescription drug costs, neither before nor after a Republican president signed the Medicare prescription drug program into law. Democrats believe competition has resulted in inequities leaving millions uninsured.
Efforts to satisfy everyone litter the road to health-care reform. Neither party considered scrapping the current system because both parties guard victories from past battles that established and modified Medicare and Medicaid. According to Beaufort B. Longest, University of Pittsburgh professor of health policy and management, reforms must satisfy the politics of existing programs. They must stimulate Congress' desire to test the political consequences of incremental reform without committing to the unknown consequences of an entirely different health-care system, regardless of how dysfunctional the system becomes.
Vested interests protect the current system. Private insurers protect profits by retaining their freedom to define benefits and establish rates based on demographics, lifestyle and pre-existing conditions. Republicans fear economic collapse if the insurance industry is dismantled. Democrats fear that starting over would be a major setback making future compromise impossible.
And so, political tinkering continues to drive health-care reform. Obama's insurance compromise is health insurance exchanges and premium subsidies allowing insurers to expand their business, but they must operate under new rules of rate restrictions and elimination of pre-existing conditions. This compromise leaves both parties pondering the consequences, with Democrats unwilling to trust insurers to provide comprehensive benefits, while Republicans fear declining profits will bankrupt insurers.
The politics of the public-private insurance debate is fueled by emotional rhetoric. Republicans characterize Obama's panel of medical experts, who evaluate the medical effectiveness of services and evidence-based outcomes, as care-rationing "death panels". Obama, politically savvy after Clinton's health care reform defeat, is reluctant to attack insurers by pointing out that these evaluations are currently made by insurers' boards of directors who ration benefits based on profits. Other interest groups that Republicans embrace are providers, concerned with reduced reimbursements, who may opt out of the system, and employers who may cut benefits or lay off employees.
Compromise surrounds the contraception and religious-freedom issue. Republicans believe that forcing Catholic institutions to pay for contraception violates religious freedom. Democrats do not want to be labeled as infringing on religious freedom. Obama's compromise is to force the insurer, not the religious employer, to pay for contraception for employees who request it.
Republican math still adds up to a Catholic employer paying for products that include contraception. This thorny issue for both parties has some Republicans divided over the championing of a religious right issue, believing this has been their Achilles heel at election time. Obama can rely on the popular politics of free contraception, which includes many Catholics, to guide his conscience.
Obamacare is as if Congress supplied the parts to rebuild our old truck's transmission but neither party is certain how those parts connect. Most Americans simply hope that their health insurance and their old Chevy truck will provide a safe trip that is affordable to their doctors of choice.
Congress thrives on the political tug of war that dominates the slow process of reform. Democrats see Obamacare as a stepping stone to universal coverage. Republicans see Obamacare as a wealth redistribution program that will break Obama's piggy bank. The Congressional Budget Office estimates that Obamacare will cost almost $1 trillion over the next decade, but will reduce the federal budget deficit.
Obamacare's imprint on the healthcare system and the economy will be monumental, and future opposition and compromise will force constant adjustment of the nuts and bolts of Obamacare.There is one certainty: Politics will continue shaping reform of the health-care system.
Dr. James C. Paladino has practiced general dentistry in Gainesville since 1976 and is president-elect of the Alachua County Dental Association.
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