There is another important role for Congress: it should avoid moving backward on health reform. While I have always been interested in improving the law—and signed 19 bills that do just that—my administration has spent considerable time in the last several years opposing more than 60 attempts to repeal parts or all of the ACA, time that could have been better spent working to improve our health care system and economy.
In some instances, the repeal efforts have been bipartisan, including the effort to roll back the excise tax on high-cost employer-provided plans. Although this provision can be improved, such as through the reforms I proposed in my budget, the tax creates strong incentives for the least-efficient private-sector health plans to engage in delivery system reform efforts, with major benefits for the economy and the budget.
It should be preserved. While historians will draw their own conclusions about the broader implications of the ACA, I have my own. These lessons learned are not just for posterity: I have put them into practice in both health care policy and other areas of public policy throughout my presidency.
The first lesson is that any change is difficult, but it is especially difficult in the face of hyperpartisanship. Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported. For example, they supported a fully funded risk-corridor program and a public plan fallback in the Medicare drug benefit in but opposed them in the ACA. They supported the individual mandate in Massachusetts in but opposed it in the ACA.
Moreover, through inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation, Republicans undermined ACA implementation efforts.
We could have covered more ground more quickly with cooperation rather than obstruction. It is not obvious that this strategy has paid political dividends for Republicans, but it has clearly come at a cost for the country, most notably for the estimated 4 million Americans left uninsured because they live in GOP-led states that have yet to expand Medicaid.
Quiz Ref ID The second lesson is that special interests pose a continued obstacle to change. We worked successfully with some health care organizations and groups, such as major hospital associations, to redirect excessive Medicare payments to federal subsidies for the uninsured. Yet others, like the pharmaceutical industry, oppose any change to drug pricing, no matter how justifiable and modest, because they believe it threatens their profits.
But we also need to reinforce the sense of mission in health care that brought us an affordable polio vaccine and widely available penicillin. The third lesson is the importance of pragmatism in both legislation and implementation.
Simpler approaches to addressing our health care problems exist at both ends of the political spectrum: the single-payer model vs government vouchers for all. Yet the nation typically reaches its greatest heights when we find common ground between the public and private good and adjust along the way. That was my approach with the ACA. We engaged with Congress to identify the combination of proven health reform ideas that could pass and have continued to adapt them since. This includes abandoning parts that do not work, like the voluntary long-term care program included in the law.
It also means shutting down and restarting a process when it fails. When HealthCare. Both the process and the website were successful, and we created a playbook we are applying to technology projects across the government. I often think of a letter I received from Brent Brown of Wisconsin. We can help them. I will repeat what I said 4 years ago when the Supreme Court upheld the ACA: I am as confident as ever that looking back 20 years from now, the nation will be better off because of having the courage to pass this law and persevere.
As this progress with health care reform in the United States demonstrates, faith in responsibility, belief in opportunity, and ability to unite around common values are what makes this nation great.
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Figure 1. View Large Download. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Published December 3, Accessed June 14, Health spending in OECD countries: obtaining value per dollar.
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Is health insurance good for your financial health? But on health care she was torn. Joe wanted Obamacare repealed. But she was reluctant to say that health care is a right.
I work really hard. I deserve a little more than the guy who sits around. A right makes no distinction between the deserving and the undeserving, and that felt perverse to Maria and Joe. The Duttons were doing all they could to earn a living and pay their taxes—taxes that helped provide free health care for people who did nothing to earn it. Meanwhile, they faced thousands of dollars in medical bills themselves. That seemed wrong.
And in their view government involvement had only made matters worse. Such feelings are widely shared. Some people see rights as protections provided by government.
But others, like the Duttons, see rights as protections from government. Tim Williams, one of my closest childhood friends, disagreed with the Duttons. Tim is a quiet fifty-two-year-old with the physique of a bodybuilder—he once bench-pressed me when we were in high school—and tightly cropped gray hair that used to be flame red.
He survived metastatic melanoma, in the nineties, and losing his job selling motorcycles, during the great recession. He went through a year of chemotherapy and, later, three years without a job.
He can figure out how to fix and build almost anything, but, without a college degree, he had few employment options. The plant was built in the nineteen-fifties. We walked among giant pipes and valves and consoles that controlled the flow of water from local ground wells through a series of huge pools for filtration, softening, and chlorination, and out to the water towers on the tallest ridges surrounding the town.
The low hum of the pump motors churned in the background. An essential function of government, therefore, is to insure that people have clean water. Joe wanted government to step back; Tim wanted government to step up. The divide seemed unbridgeable. Yet the concerns that came with each viewpoint were understandable, and I wondered if there were places where those concerns might come together. Here self-reliance is a totemic value.
Athens, Ohio, is a place where people brew their own beer, shoot their own deer, fix their own cars also grow their own weed, fight their own fights, get their own revenge. People here are survivors. Monna French was one.
She was fifty-three years old and the librarian at Athens Middle School. When Monna and her husband divorced, litigation over the business left her with no income or assets. She held down five part-time jobs, working as a teaching assistant for three different schools during the day, bartending at night, and selling furniture at Odd Lots department store on weekends, while her parents helped with the kids.
Finally, she got the librarian job. But it meant that her family had health insurance, and a roof over their heads. She also met Larry, an iron worker and Vietnam veteran, who became her second husband. He had two children, but he was older and they were grown. Together, Monna and Larry had a child of their own, named Macie. Then, thirteen years ago, Maggie, at age sixteen, was killed in a car accident.
After twenty-two years as a librarian, Monna still makes only sixteen dollars and fifty cents an hour. Her take-home pay is less than a thousand dollars a month, after taxes and health-insurance contributions. Her annual deductible is three thousand dollars. Larry, now seventy-four, has retired, and his pension, military benefits, and Medicare helped keep them afloat.
For all her struggles, though, Monna is the kind of person who is always ready to offer a helping hand. She was the vice-president of her local union, one of the largest in the county, which represents school-bus drivers, clerical staff, custodians, and other non-certified workers. In fact, she knew a lot.
And, as she spoke, I thought I glimpsed a place where the health-care divide might just allow a bridge. Monna considered herself a conservative. She could quit her job and get Medicaid free, she pointed out, just as some of her neighbors had. I mean, how much responsibility do tax-paying people like me have? How much is too much? Her eighty-three-year-old mother, who has dementia and requires twenty-four-hour care, was also on Medicaid.
That was different, Monna told me. Liberals often say that conservative voters who oppose government-guaranteed health care and yet support Medicare are either hypocrites or dunces. But Monna, like almost everyone I spoke to, understood perfectly well what Medicare was and was glad to have it. From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances.
There is genuine reciprocity. Others need more. This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get. Understanding this seems key to breaking the current political impasse. The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy.
In the American health-care system, however, different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another. The Oxford political philosopher Henry Shue observed that our typical way of looking at rights is incomplete.
People are used to thinking of rights as moral trump cards, near-absolute requirements that all of us can demand. But, Shue argued, rights are as much about our duties as about our freedoms. Even the basic right to physical security—to be free of threats or harm—has no meaning without a vast system of police departments, courts, and prisons, a system that requires extracting large amounts of money and effort from others. Once costs and mechanisms of implementation enter the picture, things get complicated.
Trade-offs now have to be considered. In his analysis, basic rights include physical security, water, shelter, and health care. But how much aid and protection a society should provide, given the costs, is ultimately a complex choice for democracies. Debate often becomes focussed on the scale of the benefits conferred and the costs extracted.
Yet the critical question may be how widely shared these benefits and costs are. Arnold Jonas is another childhood friend of mine. The work he loves is in art and design—he once designed a project for the Smithsonian—but what usually pays the bills is physical labor or mechanical work.
He lives from paycheck to paycheck. But when I asked him about health care he could only shake his head. He got a health-care plan through an insurance-agent friend, but could only afford one with minimal benefits. Arnold, with his code of self-reliance, had eliminated nearly all sources of insecurity from his life.
But here was one that was beyond his control. A serious medical issue would cost him his income. And, having passed the age of fifty, he was just waiting for some health problem to happen. So did he feel that he had a right to health care? But the right typically plays down the reality of the needs, which drives him crazy, too.
In his view, everyone has certain needs that neither self-reliance nor the free market can meet. He can fix his house, but he needs the help of others if it catches fire. He can keep his car running, but he needs the help of others to pave and maintain the roads. And, whatever he does to look after himself, he will eventually need the help of others for his medical care. The roads are abused. For example, numerous studies have pointed to the lack of adherence to evidence-based guidelines for the treatment of heart attacks.
In particular, it has long been well established that restoring blood flow to the heart and using aspirin, beta blockers, and ACE inhibitors at the appropriate times significantly reduce deaths resulting from heart attacks. Although some patients do not receive the care they need, others receive more and more expensive care than necessary. Research on geographic variation in health-care practices and costs confirms this point. For example, Medicare expenditures per eligible recipient vary widely across regions, yet areas with the highest expenditures do not appear to have better health outcomes than those with the lowest expenditures; indeed, the reverse seems to be true.
Cost This observation brings me to a third important challenge for health-care reform: controlling costs. The problem here is not only the current level of health-care spending U. Per capita health-care spending in the United States has increased at a faster rate than per capita income for a number of decades.
Should that trend continue, as many economists predict it will, the share of income devoted to paying for health care will rise relentlessly. A piece of wisdom attributed to the economist Herbert Stein holds that if something cannot go on forever, it will stop.
At some point, health-care spending as a share of GDP will stop rising, but it is difficult to guess when that will be, and there is little sign of it yet. Although the high cost of health care is a frequently heard complaint, it is important to note that a substantial portion of the cost increases that we have seen in recent decades reflects improvements in both the quality and quantity of care delivered rather than higher costs of delivering a given level of care.
Notably, new technologies, despite greatly adding to cost in many cases, have also yielded significant benefits in the form of better health. People put great value on their health, and it is not surprising that, as our society becomes wealthier, we would choose to spend more on health-care services. Indeed, although quantifying the economic value of improved health and greater expected longevity is difficult, most researchers who have undertaken an exercise of this type find that, on average, the health benefits of new technologies and other advances have significantly exceeded the economic costs.
That said, the evidence also suggests that the cost of health care in the United States is greater than necessary to allow us to achieve the levels of health and longevity we now enjoy. I have already mentioned research that finds large regional differences in the cost of treating a given condition, with high-cost areas showing no better results. The slow diffusion of the use of aspirin and beta blockers for treating heart-attack patients shows that cheap, effective treatments are not always used, potentially leading to higher costs and worse outcomes.
Moreover, because insurance companies and the government play such prominent roles in financing health care, patients and doctors have far less incentive to consider the extra costs of optional tests or treatments. But, as we all know, although testing and treatment decisions may be undertaken on the presumption that "someone else will pay," the public eventually pays for all these costs, either through higher insurance premiums or higher taxes.
The effects of high health-care costs on government budgets deserve special note. In the United States, a large and growing portion of both federal and state expenditures is for subsidized health insurance.
In , federal spending on Medicare and Medicaid was about 6 percent of total non-interest federal spending. Today, that share is about 23 percent. Because of rising costs of health care and the aging of the population, the CBO projects that, without reform, Medicare and Medicaid will be about 35 percent of non-interest federal spending in Rapid increases in health spending also portend increasingly difficult access to health services for people with lower incomes.
The Medicare Part D program, which assists seniors with the costs of prescription drugs, is an example. However, to continue limiting the effects of rising medical costs on household budgets, the government may have to absorb an increasing proportion of the nation's total bill for health care, putting even greater pressure on government budgets than official projections suggest.
Taking on these challenges will be daunting. Because our health-care system is so complex, the challenges so diverse, and our knowledge so incomplete, we should not expect a single set of reforms to address all concerns.
Rather, an eclectic approach will probably be needed. In particular, we may need to first address the problems that seem more easily managed rather than waiting for a solution that will address all problems at once.
Thinking About Solutions In health-care reform, it is certainly easier to pose questions than to provide answers. Moreover, even putting aside the scope and technical complexities of the problems we face, the types of reforms we choose will depend importantly on value judgments and the tradeoffs made among social objectives. Such choices are appropriately left to the public and their elected representatives. Consequently, I will have little to say here regarding specific proposals.
However, I will suggest a few questions and considerations that those seeking reform might wish to keep in mind.
Regarding access, one important consideration is that people who are uninsured are not all alike. They include people who have low incomes, people who may not be poor but have costly pre-existing health conditions, those whose employers do not offer group health insurance and who cannot afford to buy insurance in the more-expensive nongroup market, and people who are eligible for Medicaid or other programs but for some reason have not enrolled.
Some people who can afford health insurance do not purchase it, presumably because they do not anticipate having significant medical expenses.
Broadening access to health care may thus require us to consider a mix of policies. The following are some of the questions with which we will have to wrestle. First, should enrollment in a health insurance program be mandated, or at least strongly encouraged, for example, through tax incentives?
Supporters argue that mandates lead to better risk pooling and prevent those who could afford insurance but choose not to buy it from "free-riding" on the public safety net. Opponents argue that mandates infringe on what should be an individual choice and may require a substantial government budgetary commitment to help those who cannot afford insurance on their own to meet the mandate. Second, should we continue to rely on employer-provided health insurance as the key element of our system?
The employees of large companies in particular typically constitute a good risk-sharing pool, allowing insurance to be provided at a lower overall cost. But the dominance of the insurance market by employer-provided plans means that the market for individual and small-group policies is underdeveloped and that the cost of such coverage is very high. Employer-based systems also reduce the portability of health insurance between jobs, which reduces labor mobility and the efficiency of the labor market as well as creating a burden for those changing jobs.
Third, to help people with costly pre-existing conditions, should we impose requirements on insurance companies to accept all applicants and mandate the conditions that must be covered? Doing so would help some people obtain coverage, but the resulting increases in insurance premiums might exclude others. An alternative approach would be to promote bare-bones, high-deductible policies that are affordable and attractive to healthy people while offering government help to those who need coverage for costly conditions.
Finally, to what extent are we willing to use public funds to reduce the number of those who are uninsured, for example, by providing subsidies to low-income people not covered by Medicaid or to people, such as the self-employed, who find it difficult to obtain affordable coverage in the non-group market?
How would we finance additional spending?
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