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  • BIOETHICS FORUM ESSAY

Health Reform at Six Months, and Obstacles Ahead

Six months ago, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law after nearly a year of legislative wrangling and decades of promises from both sides of the aisle. With the six-month anniversary of passage on September 23, the most meaningful reforms from this landmark piece of legislation began to take effect.

Perhaps the reforms that will have the most important long-term impact on our health care system are those aimed at protecting consumers from insurance practices that have made coverage inaccessible and expensive for millions. Individual and group health plans are now prohibited from placing lifetime limits on the dollar value of coverage.

Furthermore, insurers can no longer deny coverage to children because of pre-existing conditions, such as asthma. As of last July, adults with pre-existing conditions who had been uninsured for at least six months were able to join high risk pools. These pools, with some federal government support, are meant to make insurance available for more individuals until 2014, when pre-existing condition prohibitions will include everyone.

Unfortunately, these meaningful provisions are already facing resistance. Insurers, including Wellpoint and Cigna, in some states stopped offering child-only policies just days before the new provisions took effect. Their attempt to avoid the restrictions created by the law has prompted proponents of reform to question the morality of insurance business practices. Concern about unethical insurance practices was a key impetus for reform in the first place.

A number of other reforms have also taken effect. Dependent young adults can now stay on their parents’ health insurance plans until the age of 26, helping to relieve some of the burdens faced by this demographic as they navigate a world of student loans, career uncertainties, and expectations of adulthood. Insurance companies are also being held more accountable, as new health plans must implement an effective process for allowing consumers to appeal health decisions and establish an external review process.

Finally, new health plans are required to provide coverage without any copayments for preventive services rated A or B (with “good” or “fair” evidence of improving health outcomes, and benefits outweighing harms) by the U.S. Preventive Services Task Force. Those services include immunizations and preventive care for infants, children, and adolescents; mammography for women over age 50, and colonoscopy for adults starting at age 50. In addition, $5 billion have been appropriated for fiscal years 2010 through 2014 to support prevention and public health measures, such as increased funding for community-based tobacco cessation programs, initiatives to reduce diabetes and heart disease, and cancer screenings and vaccine programs. The implementation of these provisions is a critical step toward meaningful reform of our health care system, but they are not without resistance.

In what was likely not a coincidence, Congressional Republicans released their Pledge to America on the same day these changes took effect. Among the pledges to “advance policies that promote greater liberty, wider opportunity, a robust defense, and national economic prosperity” is a commitment to “repeal and replace the government takeover of health care.” Republicans claim that the health care law will force employers to fire workers in order to meet new requirements; seniors will bear the brunt of costs as they lose Medicare coverage; individuals will be overly burdened with increased taxation from the law’s provisions, such as the individual mandate; and the country will see increased deficits based.

The accuracy of these arguments aside, the Republicans offer little in the way of sensible solutions or alternatives. Their piecemeal solutions would likely only have a marginal impact on health care spending and would fail to ensure meaningful access to care and coverage that Americans deeply desire.

While their proposal for medical liability reform may reduce the occurrence of “junk lawsuits” and rein in defensive medicine, a recent study suggests tort reform has only modest potential to exert downward pressure on overall health spending. The Republicans’ aim to make insurance available across state lines suggests that this would not be possible under the existing law. In reality, the statewide insurance exchanges, to be established in 2014, would have the option to coordinate with surrounding states to create regional exchanges. Contrary to Republican assertions, exchanges will likely vastly improve the number of qualifying plans that individuals and employers can choose from, and create meaningful competition that will reduce premiums and administrative costs.

The Pledge seeks to bolster and protect what has long been a core tenet of Republican health reform plans, health savings accounts. While they criticize the provision in ACA that forbids using money from health savings accounts to pay for over-the-counter medicine, they ignore the significant problems that the savings accounts pose to the health system. While beneficial for some individuals, health savings accounts are not a sustainable model for those who require high cost medical services or cannot afford to set aside money in a savings account. In some cases, individuals have even used money from their health savings accounts to pay for goods and services not related to health ACA increases the tax penalty for doing so.

Republicans also promise common-sense reforms to “strengthen the doctor-patient relationship.” This ambiguous assertion seems to suggest that the current law undermines the doctor-patient relationship but offers no explanation of the current problem or what reforms they propose.

Finally, and perhaps most unclear, is the Republicans’ assertion that they will “ensure access for patients with pre-existing conditions.” This section of the Pledge appears to offer consumer protections similar to those in the current law, but if read closely one realizes that this may not be the case. They seek to make it illegal “for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition.” Unlike the ACA, which makes it illegal for an insurance company to deny coverage to a new applicant because of a pre-existing condition, the Republican plan says simply that insurers cannot deny coverage to existing policyholders. On its face, it appears as though Republicans are looking to protect vulnerable health insurance consumers, but their preexisting condition proposal would not help the millions of Americans who do not yet have insurance.

The Republicans’ final indictment of the health care law is the Maze of Bureaucracies, a flowchart of what government entities will be expanded or created because of the law. The flowchart evokes the same confused and slightly fearful reaction as the slide from the U. S. military that prompted General Stanley McChrystal to say, “When we understand that slide, we’ll have won the [Afghan] war.” Do we have to understand everything about health care reform to appreciate what it does for us?

Republican leadership sounds committed to repeal of the health care reform law, but does it really reflect the will of the people? A survey of Americans might suggest so (approval is around 30 percent and disapproval around 40 percent), but a recent A.P. poll reveals more nuance to public opinion. In fact, four in ten adults think that the new law did not go far enough to change the health care system (more specifically, 61 percent of those who supported the law and 23 percent of those who opposed the law wished it had gone further).

Health care remains an issue high on the minds of Americans. Upwards of 72 percent still think it is very important or extremely important. Whether or not Americans approve of reform, over 70 percent feel that Americans should have better access to care, that health care costs for individuals and employers should be lower, and that Americans should have continually improved health care services. Given the importance of health care to Americans and the uncertainty about how support will change as provisions begin to take effect, repeal of health care would be presumptuous, particularly given the scarcity of practical alternatives from those who oppose it.

Perhaps the real opposition to health care reform derives from a failure of President Obama and Democrats to effectively communicate what it means for us. The most concise, informative, and unbiased account of the law and its implementation, in my opinion, comes from the Kaiser Family Foundation, which launched a new Web site last week that includes a number of valuable resources that make clear what reform means for Americans. Whether better transmission of the positive impacts of passage and implementation of ACA is the answer is uncertain, but one thing is clear. If Democrats fail to speak up in the next month, they may well lose control of Congress and face the worst possible scenario: repeal of landmark legislation, decades in the making, that has the potential to make quality health care affordable and accessible for millions of Americans.

Ross White is a research assistant at The Hastings Center.

Published on: September 29, 2010
Published in: Health Care Reform & Policy

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